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Transcription

March 2004
2007
Nursing Best Practice Guideline
Shaping the future of Nursing
Adult Asthma Care
Guidelines for Nurses: Promoting
Control of Asthma
Greetings from Doris Grinspun
Executive Director
Registered Nurses Association of Ontario
It is with great excitement that the Registered Nurses Association of Ontario (RNAO)
disseminates this nursing best practice guideline to you. Evidence-based practice supports
the excellence in service that nurses are committed to deliver in our day-to-day practice.
We offer our endless thanks to the many institutions and individuals that are making
RNAO’s vision for Nursing Best Practice Guidelines (NBPGs) a reality. The Ontario Ministry
of Health and Long-Term Care recognized RNAO’s ability to lead this project and is providing multi-year
funding. Tazim Virani–NBPG project director–with her fearless determination and skills, is moving the project
forward faster and stronger than ever imagined. The nursing community, with its commitment and passion
for excellence in nursing care, is providing the knowledge and countless hours essential to the creation and
evaluation of each guideline. Employers have responded enthusiastically to the request for proposals (RFP),
and are opening their organizations to pilot test the NBPGs.
Now comes the true test in this phenomenal journey: will nurses utilize the guidelines in their day-to-day practice?
Successful uptake of these NBPGs requires a concerted effort of four groups: nurses themselves, other
healthcare colleagues, nurse educators in academic and practice settings, and employers. After lodging
these guidelines into their minds and hearts, knowledgeable and skillful nurses and nursing students need
healthy and supportive work environments to help bring these guidelines to life.
We ask that you share this NBPG, and others, with members of the interdisciplinary team. There is much to
learn from one another. Together, we can ensure that Ontarians receive the best possible care every time they
come in contact with us. Let’s make them the real winners of this important effort!
RNAO will continue to work hard at developing and evaluating future guidelines. We wish you the
best for a successful implementation!
Doris Grinspun, RN, MScN, PhD (candidate)
Executive Director
How to Use this Document
This nursing best practice guideline is a comprehensive document that provides
resources necessary to support evidence-based nursing practice related to the control of
asthma in adults. Specifically, this guideline focuses on assisting nurses working in diverse
practice settings in providing basic asthma care for adults and contains recommendations
for Registered Nurses and Registered Practical Nurses on best nursing practices in the key
interventions of assessment, education and referral.
While best practice guidelines represent a statement of best practice based on the best
available evidence, they are not intended to be applied in a ‘cookbook fashion’ and replace
the nurse’s judgment for the individual client. This document needs to be reviewed and
applied, based on the specific needs of the organization or practice setting/environment, as
well as the needs and wishes of the client.
Nurses, other healthcare professionals and administrators, who are leading and facilitating
practice changes, will find this document valuable for the development of such things as policies,
procedures, protocols, educational programs, assessment and documentation tools. It is highly
recommended that practice settings adapt these guidelines in formats that would meet local
needs. This guideline provides some suggested formats for such local adaptation and tailoring.
Organizations wishing to use this guideline may decide to do so in a number of ways:
Assess current nursing and healthcare practices using the recommendations
in the guideline.
Identify recommendations that will address identified needs or gaps in services.
Systematically develop a plan to implement the recommendations using associated
tools and resources.
RNAO is interested in hearing how you have implemented this guideline. Please contact
us to share your story. Implementation resources will be made available through the RNAO
website at www.rnao.org/bestpractices to assist individuals and organizations to implement
best practice guidelines.
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Adult Asthma Care Guidelines for Nurses: Promoting Control of Asthma
Guideline Development Panel Members
Lisa Cicutto, RN, PhD, ACNP, CAE
Julie Duff Cloutier, RN, BScN, MSc, CAE
Team Leader
Assistant Professor
Assistant Professor
School of Nursing
Faculty of Nursing, University of Toronto
Laurentian University
ACNP – Respiratory
Sudbury, Ontario
The Asthma and Airway Centre –
University Health Network
Toronto, Ontario
2
Khiroon Kay Khan, RN, CAE,
NARTC/Diploma in Asthma and COPD
Clinical Nurse Educator
Pat Hill Bailey, RN, BN, MHSc, PhD
The Asthma and Airway Centre
Professor
University Health Network –
School of Nursing
Toronto Western Hospital
Toronto, Ontario
Sudbury, Ontario
Donna Lockett, PhD
Ann Bartlett, RN, BScN, CAE,
NARTC/Diploma in COPD
Research Associate
Nurse Clinician
Community Health Research Unit
Firestone Institute for Respiratory Health
Ottawa, Ontario
University of Ottawa
St Joseph’s Healthcare
Hamilton, Ontario
Heather McConnell, RN, BScN, MA(Ed)
RNAO Project Staff – Facilitator
Janice Bissonnette, RN, MScN, CAE, CNCC(C)
Project Manager, Nursing Best Practice
Clinical Nurse Specialist
Guidelines Project
Queensway – Carleton Hospital
Ottawa, Ontario
Toronto, Ontario
Naomi Cornelius, RPN*
Manager, Resident Care/Service
Needs Coordinator
Churchill Place Retirement Home
Oakville, Ontario
* Contributed to the initial development of the guideline.
Jennifer Olajos-Clow, RN, BA/BPHE, BNSc,
MSc, CAE
Dale Stedman, RN
Asthma Educator
Saint Elizabeth Health Care
Asthma Education Centre
Toronto, Ontario
Respiratory Coordinator/Consultant
Kingston General Hospital
Kingston, Ontario
Ruth Pollock, RN, MScN
Professional Practice Leader – Nursing
Cornwall General Hospital
Cornwall, Ontario
3
Acknowledgement
Stakeholders representing diverse perspectives were solicited for their feedback
and the Registered Nurses Association of Ontario wishes to acknowledge the
following for their contribution in reviewing this Nursing Best Practice Guideline.*
Dr. Wally Bartfay
Lenora Duhn, RN, MSc
Queen’s University
Clinical Nurse Specialist
Kingston, Ontario
Kingston, Ontario
Charlene Bennison, BScPhm, CAE, MEd
Pharmacist
Dr. Anthony D’Urzo
North Bay, Ontario
Family Physician
Toronto, Ontario
Gabrielle Bridle, RPN
President, Registered Practical Nurses
Donna George, RPN
Association of Ontario
Retired
Mississauga, Ontario
Aylmer, Ontario
Christine Burchat, BSPhm
Rosario Holmes, BS, MA, RRT
Pharmacist
Asthma Education Centre
Ontario Lung Association
Ottawa, Ontario
Ottawa, Ontario
Paula Burns, RRCP, BSc, MAEd, CAE
Patricia Hussack, RN
Consumer Reviewer
Research Nurse
The Michener Institute for
St. Joseph’s Health Care
Applied Health Sciences
McMaster University
Toronto, Ontario
Hamilton, Ontario
Corinne Chapman, RN, BA, MHSc
Dr. Susan Janson, RN, ANP, DNSc, FAAN
Credit Valley Hospital
Professor/Alumnae Chair
Department of Community Health Systems
Adjunct Professor, Department of Medicine
Tracey Crosbie
University of California
Director, Registered Practical Nurses
San Francisco, California
Association of Ontario
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Dr. Allan Kaplan
Kimberly Peterson
Family Physician
Chief Nursing Officer and
Richmond Hill, Ontario
Program Officer of Medicine
Judith Kleffman
Cornwall, Ontario
Consumer Reviewer
Kingston, Ontario
Terry Richmond, RN
Dr. Diane Lougheed
Kingston, Ontario
Respirologist
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Shelley Rochette, RN
Kingston, Ontario
Ottawa, Ontario
Dr. Josiah Lowry
Family Physician
Cathy Seymour, RN
Orillia, Ontario
Kingston, Ontario
Dr. Warren McIssac
General Internal Medicine
Joanne Williscroft, RN(EC)
Mt Sinai Hospital
Respiratory Care Clinic
Toronto, Ontario
Cornwall, Ontario
Alwyn Moyer, RN, MSc(A), PhD
Adjunct Professor
Karen Zalan, BScPT, CAE
Physiotherapist
Ottawa, Ontario
Sudbury Regional Hospital
Sudbury, Ontario
Allistair Packman
Pharmacist
Kingston, Ontario
Focus Group
Ottawa, Ontario
* The above acknowledgements reflect
the information provided by the
stakeholder at the time the feedback
was provided.
Karen Carruthers, RN
Staff Nurse
MedicineProject Manager Charting
Systems
Nancy Flynn, RN, BScN
Nurse Manager
Medicine/Palliative
Linda Hay, RN, BScN
Palliative Care Coordinator
Kristine Kennedy RN, BScN
Staff Nurse ICU/CCU
Lisa Lynch RN
Staff Nurse Surgery
Evelyn Reddy RN,
Team Leader Medicine
Shay Savoy-Bird RN, BScN
Nurse Manager Surgery
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RNAO wishes to acknowledge the following organization in Mississauga, Ontario
for their role in pilot testing this guideline:
Trillium Health Centre
RNAO sincerely acknowledges the leadership and dedication of the
researchers who have directed the evaluation of the Nursing Best
Practice Guidelines Project. The Evaluation Team is comprised of:
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8
Principal Investigators:
Evaluation Team:
Nancy Edwards, RN, PhD
Barbara Davies, RN, PhD
Maureen Dobbins, RN, PhD
Jenny Ploeg, RN, PhD
Jennifer Skelly, RN, PhD
McMaster University
Patricia Griffin, RN, PhD
Project Staff:
Barbara Helliwell, BA(Hons); Marilynn Kuhn, MHA; Diana Ehlers, MA(SW), MA(Dem);
Christy-Ann Drouin, BBA; Sabrina Farmer, BA; Mandy Fisher, BN, MSc(cand); Lian Kitts, RN;
Elana Ptack, BA
Contact Information
Registered Nurses Association
of Ontario
Registered Nurses Association
of Ontario
Nursing Best Practice Guidelines Project
Head Office
111 Richmond Street West, Suite 1100
438 University Avenue, Suite 1600
Toronto, Ontario
Toronto, Ontario
M5H 2G4
M5G 2K8
Adult Asthma Care Guidelines for Nurses:
Promoting Control of Asthma
Disclaimer
These best practice guidelines are related only to nursing practice and not intended to take into
account fiscal efficiencies. These guidelines are not binding for nurses and their use should be
flexible to accommodate client/family wishes and local circumstances. They neither constitute
a liability or discharge from liability. While every effort has been made to ensure the accuracy
of the contents at the time of publication, neither the authors nor RNAO give any guarantee as
to the accuracy of the information contained in them, nor accept any liability, with respect to
loss, damage, injury or expense arising from any such errors or omissions in the contents of this
work. Any reference throughout the document to specific pharmaceutical products as examples
does not imply endorsement of any of these products.
Copyright
With the exception of those portions of this document for which a specific prohibition or
limitation against copying appears, the balance of this document may be produced, reproduced
and published in its entirety, in any form, including in electronic form, for educational or noncommercial purposes only, without requiring the consent or permission of the Registered
Nurses Association of Ontario, provided that an appropriate credit or citation appears in the
copied work as follows:
Registered Nurses Association of Ontario (2004). Adult Asthma Care Guidelines for Nurses:
Promoting Control of Asthma. Toronto, Canada: Registered Nurses Association of Ontario.
9
table of contents
Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Interpretation of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Responsibility for Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
10
Purpose and Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Guideline Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Background Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Practice Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Education Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Organization & Policy Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Evaluation & Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Implementation Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Process for Update/Review of Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Appendix A – Search Strategy for Existing Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Appendix B – Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Appendix C – Assessing Asthma Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Appendix D – Asthma Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Appendix E – Device Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Appendix F – What is an Asthma Action Plan? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Appendix G – Sample Asthma Action Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Appendix H – Peak Flow Monitoring Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Appendix I – How to Use a Peak Flow Meter (PFM) . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Appendix J – Tips for Improving Adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Appendix K – Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Appendix L – Asthma Clinics in Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Appendix M – Description of the Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Appendix N – Implementation Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
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Summary of Recommendations
RECOMMENDATION
Assessment of
1.0
Asthma Control
*LEVEL OF EVIDENCE
All individuals identified as having asthma, or suspected of having asthma,
will have their level of asthma control assessed by the nurse.
1.1
Every client should be screened to identify those most likely to be
Level IV
affected by asthma. As part of the basic respiratory assessment,
nurses should ask every client two questions:
Have you ever been told by a physician that you have asthma?
Have you ever used a puffer/inhaler or asthma medication
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for breathing problems?
1.2
For individuals identified as having asthma or suspected of having
Level IV
asthma, the level of asthma control should be assessed by the nurse.
Nurses should be knowledgeable about the acceptable parameters
of asthma control, which are:
use of inhaled short-acting ß2 agonist <4 times/week
(unless for exercise);
1.3
experience of daytime asthma symptoms <4 times/week;
experience of night time asthma symptoms <1 time/week;
normal physical activity levels;
no absence from work or school; and
infrequent and mild exacerbations.
For individuals identified as potentially having uncontrolled asthma,
Level IV
the level of acuity needs to be assessed by the nurse and an appropriate
medical referral provided, i.e., urgent care or follow-up appointment.
Asthma Education
2.0
Asthma education, provided by the nurse, must be an essential component
of care.
2.1
The client’s asthma knowledge and skills should be assessed and where
gaps are identified, asthma education should be provided.
* See pg. 16 for details regarding “Interpretation of Evidence”.
Level I
RECOMMENDATION
2.2
Action Plans
3.1
LEVEL OF EVIDENCE
Education should include as a minimum, the following:
basic facts about asthma;
roles/rationale for medications;
device technique(s);
self-monitoring; and
action plans.
Every client with asthma should have an individualized asthma action
Level IV
Level I
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plan for guided self-management based on evaluation of symptoms
with or without peak flow measurement, developed in partnership
with a healthcare professional.
3.2
For every client with asthma, the nurse needs to assess for use and
Level V
understanding of the asthma action plan. If a client does not have
an action plan, the nurse needs to provide a sample action plan,
explain its purpose and use, and coach the client to complete the
plan with his/her asthma care provider.
3.3
Where deemed appropriate, the nurse should assess, assist and
Level IV
educate clients in measuring peak expiratory flow rates. A standardized
format should be used for teaching clients how to use peak
flow measurements.
Medications
4.0
Nurses will understand and be able to discuss with clients their medications.
4.1
Nurses will understand and be able to discuss the two main categories
Level IV
of asthma medications (controllers and relievers) with their clients.
`
4.2
All asthma clients should have their inhaler/device technique assessed
by the nurse to ensure accurate use. Clients with sub-optimal
technique will be coached in proper inhaler/device use.
Level I
RECOMMENDATION
Referrals
5.0
The nurse will facilitate referrals as appropriate.
5.1
Clients with poorly controlled asthma should be referred to
LEVEL OF EVIDENCE
Level II
their physician.
5.2
All clients should be offered links to community resources.
Level IV
5.3
Clients should be referred to an asthma educator in their community,
Level IV
if appropriate and available.
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Education
6.0
Recommendations
Organization and
Nurses working with individuals with asthma must have the
Level IV
appropriate knowledge and skills to:
7.0
Policy Recommendations
identify the level of asthma control;
provide basic asthma education; and
conduct appropriate referrals to physician and community resources.
Organizations should have available placebos and spacer devices
Level IV
for teaching, sample templates of action plans, educational materials,
and resources for client and nurse education and where indicated,
peak flow monitoring equipment.
8.0
Organizations must promote a collaborative practice model within
Level IV
an interdisciplinary team to enhance asthma care.
9.0
Organizations need to ensure that a critical mass of health
Level V
professionals are educated and supported to implement the asthma
best practice guidelines in order to ensure sustainability.
10.0 Agencies and funders need to allocate appropriate resources to
ensure adequate staffing and a positive healthy work environment.
Level V
RECOMMENDATION
LEVEL OF EVIDENCE
11.0 Nursing best practice guidelines can be successfully implemented
Level IV
only when there are adequate planning, resources, organizational
and administrative support, and appropriate facilitation. Organizations
may develop a plan for implementation that includes:
An assessment of organizational readiness and barriers to education.
Involvement of all members (whether in a direct or indirect
supportive function) who will contribute to the implementation
process.
Dedication of a qualified individual to provide the support needed
for the education and implementation process.
Ongoing opportunities for discussion and education to reinforce
the importance of best practices.
Opportunities for reflection on personal and organizational
experience in implementing guidelines.
In this regard, RNAO (through a panel of nurses, researchers and
administrators) has developed the Toolkit: Implementation of Clinical
Practice Guidelines based on available evidence, theoretical
perspectives and consensus. The Toolkit is recommended for guiding
the implementation of Adult Asthma Care Guidelines for Nurses –
Promoting Control of Asthma.
15
Interpretation of Evidence
The recommendations made in this best practice guideline
have been
critically reviewed and categorized by level of evidence. The following taxonomy provides the
definitions of the levels of evidence and the rating system (Boulet et al., 1999).
LEVEL I
Evidence is based on randomized controlled trials (or meta-analysis of such
trials) of adequate size to ensure a low risk of incorporating false-positive
or false-negative results.
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LEVEL II
Evidence is based on randomized controlled trials that are too small to
provide Level I evidence. They may show either positive trends that are not
statistically significant or no trends and are associated with a high risk of
false-negative results.
LEVEL III
Evidence is based on non-randomized controlled or cohort studies, case
series, case-control studies or cross-sectional studies.
LEVEL IV
Evidence is based on the opinion of respected authorities or expert
committees as indicated in published consensus conferences or guidelines.
LEVEL V
Evidence is based on the opinions of those who have written and reviewed
the guideline, based on their experience, knowledge of the relevant literature
and discussion with their peers.
Responsibility for Development
The Registered Nurses Association of Ontario (RNAO), with funding from the
Ministry of Health and Long-Term Care, has embarked on a multi-year project of nursing best
practice guideline development, pilot implementation, evaluation and dissemination. In this
third cycle of the project, one of the areas of emphasis is on the assessment and management
of asthma in adults. This guideline was developed by a panel of nurses and researchers
convened by the RNAO, conducting its work independent of any bias or influence from the
Ministry of Health and Long-Term Care.
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Purpose and Scope
The purpose of this best practice guideline is to provide nurses (RNs and RPNs)
working in diverse settings with an evidence-based summary of basic asthma care for adults.
The guideline aims to assist nurses and their clients to make informed decisions that lead to
quality care and improved outcomes (improved quality of life and overall reduction in morbidity). It is not the intent of the best practice guideline to provide a comprehensive review
of the literature or duplicate the recommendations of the Canadian Asthma Consensus
Report. Rather, this document is designed to complement and expand upon existing guidelines. This best practice guideline assists nurses who are not specialists in asthma care to
identify adults with asthma, determine whether or not their asthma is under acceptable control, provide asthma education (specifically, self-management action plans, use of
inhaler/devices and medications), facilitate appropriate referral(s), and access community
resources. It is acknowledged that successful asthma control involves a partnership with the
individual with asthma and the interdisciplinary healthcare team.
Key Points
This document focuses on assisting nurses working in diverse practice
settings in providing basic asthma care.
Nurses have an important role in promoting control of asthma through
assessment, education and referral.
Guideline Development Process
In February of 2001, a panel of nurses and researchers with expertise in asthma care,
asthma education and asthma research, from institutional, community and academic settings
was convened under the auspices of the RNAO. The panel discussed the purpose of their
work, and came to consensus on the scope of the best practice guideline. Subsequently, a
search of the literature for clinical practice guidelines, systematic reviews, relevant research
articles and websites was conducted. See Appendix A for a detailed outline of the search
strategy employed.
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Several published international guidelines have systematically reviewed the evidence related
to asthma. The adult asthma best practice development panel determined that it was not
necessary to repeat a review of all the literature and that existing guidelines would serve as a
“foundation” for guideline development.
A total of ten existing clinical practice guidelines for the assessment and management of
asthma in adults were identified that met the initial inclusion criteria:
published in English;
developed in 1995 or later;
strictly on the topic of asthma;
evidence-based (or documentation of evidence); and
accessible as a complete document.
Members of the development panel critically appraised these ten guidelines using the
“Appraisal Instrument for Clinical Guidelines” from Cluzeau et al. (1997). This instrument
allows for evaluation in three key dimensions: rigour, content and context, and application.
Following the appraisal process, several guidelines were dropped due to low rigour scores
(< 20% of criteria met). Guidelines that were identified as being developed in a systematic
way, so that their recommendations were reliably and explicitly evidence-based, were selected
as “foundation” guidelines. These documents included:
Boulet, L. P., Becker, A., Bérubé, D., Beveridge, R., & Ernst, P. (1999). Canadian asthma
consensus report. [Online]. Available: www.cmaj.ca/cgi/reprint/161/11_suppl_1/s1.pdf
Green, L., Baldwin, J., Grum, C., Erickson, S., Hurwitz, M., & Younger, J. (2000).
UMHA asthma guideline. University of Michigan Health System [Online].
Available: www.guideline.gov
Institute for Clinical Systems Improvement (2001). Health care guideline: Diagnosis
and management of asthma. ICSI Health Care Guideline. [Online].
Available: www.ICSI.org/guidelist.htm#guidelines
National Institutes of Health (1997). Guidelines for the diagnosis and management of asthma
(Rep. No. 2). NIH Publication. [Online]. Available: www.nhlbi.nih-gov/guidelines/
asthma/asthgdln.htm
Scottish Intercollegiate Guidelines Network (1996). Hospital in-patient management of
acute asthma attacks – SIGN 6. [Online]. Available: www.show.scot.nhs.uk/sign/home.htm
Scottish Intercollegiate Guidelines Network (1998). Primary care management of asthma –
SIGN 33.[Online]. Available: www.show.scot.nhs.uk/sign/home.htm
Scottish Intercollegiate Guidelines Network (1999). Emergency management of acute
asthma – SIGN 38. [Online]. Available: www.show.scot.nhs.uk/sign/home.htm
19
The recommendations from the seven foundation guidelines were compared in a summary
document using the following subheadings:
1. Criteria of control, optimal ranges, acceptable ranges.
2. Mild, moderate, and severe asthma.
3. Medication management – what, how often – adjusted to symptom control.
4. Monitoring, assessment, education, follow-up.
5. Education/Self-management, basic survival skills.
6. Indications for referral and follow-up – asthma centre/specialists.
7. Contextual – education of nurses.
20
Following the extraction of identified recommendations and content from the seven
guidelines, the panel underwent a process of review, discussion and consensus on the key
evidence-based assessment criteria and levels of severity and control, ultimately identifying
key subtopic areas for nursing intervention recommendations.
The panel members divided into subgroups to develop draft recommendations for these key
nursing interventions. This work included a critical review of the selected literature by the
member(s) of the working group, including review of the foundation guidelines, systematic
review articles, primary research studies and other supporting literature for the purpose of
drafting recommendations. Where evidence was available from randomized controlled trials
and systematic reviews, recommendations were based on these data. Where there was a lack
of evidence from high quality studies, recommendations were based on the best available
evidence or expert opinion. This process yielded an initial set of recommendations, which
were reviewed by the entire development panel for potential gaps and need for supporting
evidence, leading to consensus on a final draft set of recommendations. Recommendations
were only advanced where consensus was achieved.
This draft document was submitted to a set of external stakeholders for review and feedback
– a listing and acknowledgement of these reviewers is provided at the front of this document.
Stakeholders represented various healthcare professional groups, clients and families, as well
as professional associations. External stakeholders were asked to provide feedback using a
questionnaire consisting of open and closed-ended questions. The results were compiled
and reviewed by the development panel – discussion and consensus resulted in minor
revisions to the draft document prior to pilot testing.
A pilot implementation practice setting was identified through a “Request for Proposal”
(RFP) process. Practice settings in Ontario were asked to submit a proposal if they were
interested in pilot testing the recommendations of the guideline. The proposals underwent
an external review process and the successful applicant (practice setting) selected. A
nine-month pilot was undertaken to test and evaluate the recommendations for practice in
a community-based hospital setting (Mississauga, Ontario).
The development panel reconvened following completion of the pilot to review the
experiences of the pilot site, consider the evaluation results and review any new literature
published since the initial development phase. All these sources of information were used to
update and revise the document prior to publication.
Three new clinical practice guidelines focusing on adult asthma had been published since
the initial development phase. To ensure congruency with the development methodology,
development panel members appraised these documents using the revised version of the
Cluzeau (1997) instrument, the “Appraisal of Guidelines for Research and Evaluation
(AGREE) Instrument” (2001). All three guidelines were determined to meet the panel’s
criteria for rigour, content and context, and applicability, and were included as resources for
the revision phase. These documents included:
British Thoracic Society and the Scottish Intercollegiate Guidelines Network (2003).
British guideline on the management of asthma. [Online]. Available: www.sign.ac.uk/pdf/
sign63.pdf
Global Initiative for Asthma (2002). Global strategy for asthma management and prevention.
[Online]. Available: www.ginasthma.com
New Zealand Guideline Group (2002). Best practice evidence-based guideline. The diagnosis
and treatment of adult asthma. [Online]. Available: www.nzgg.org.nz/library/gl_complete/
asthma/full_text_guideline.pdf
21
Definition of Terms
For clinical terms not identified here, please refer to the Glossary of Terms, Appendix B.
Action Plan: A collaboratively written set of instructions that assists the client to adjust
their asthma medication and/or to seek medical attention according to their level of symptoms
and/or peak flow rate in order to maintain control.
Asthma: A chronic inflammatory disorder of the airways. Airway inflammation contributes
to airway hyperresponsiveness, airflow limitation, and recurrent episodes of wheeze, cough,
22
shortness of breath, and chest tightness. These episodes are usually associated with airflow
obstruction that is reversible either spontaneously or with treatment. Airway inflammation
contributes to airflow obstruction by causing bronchoconstriction, airway edema, mucous
plug formation, and airway wall remodeling.
Asthma Management: Establishing and maintaining control of a person’s asthma
includes education, environmental control measures, appropriate medications, action plans
and regular follow-up care.
Certified Asthma Educator (CAE): The national certification for asthma educators
in Canada, which ensures a common set of technical and teaching competencies. There are
two integral aspects of education included in the Certified Asthma Educators certification:
current knowledge about asthma, and educational theory and behaviour change process.
Chronic Obstructive Pulmonary Disease (COPD): A term that incorporates
chronic bronchitis and emphysema, which can occur singularly or in combination. In
Canada, this term does not include asthma. Asthma and COPD can co-exist.
Clinical Practice Guidelines or Best Practice Guidelines: Systematically
developed statements that assist clinicians and patients to make decisions about appropriate
management and healthcare use for specific clinical (practice) circumstances.
Consensus: A process for making policy decisions, not a scientific method for creating
new knowledge. At its best, consensus development merely makes the best use of available
information, be that research data or the collective knowledge of participants.
Control of Asthma: Acceptable asthma control is defined by the following parameters:
use of inhaled short-acting ß2 agonist <4 times/week (unless for exercise); experience of daytime asthma symptoms <4 times/week; experience of night time asthma symptoms <1
time/week; normal physical activity level; no absence from work or school; and infrequent
and mild exacerbations.
Education Recommendations:
Statements of educational requirements and
educational approaches/strategies for the introduction, implementation, and sustainability
of the best practice guideline.
Meta-analysis: Results from several studies, identified in a systematic review, that are
combined and summarized quantitatively.
Organization and Policy Recommendations: Statements of conditions required
for a practice setting that enable the successful implementation of the best practice guideline. The conditions for success are largely the responsibility of the organization, although
they may have implications for policy at a broader government or societal level.
Practice Recommendations: Statements of best practice directed at the practice of
healthcare professionals that are ideally evidence-based.
23
Background Context
Overview
Asthma is one of the most prevalent chronic conditions affecting 2.3 million Canadians over
the age of 4 years (Statistics Canada, 2000), with an estimated total cost of between $504 million
and $648 million in 1991 (Krahn et al., 1996).
According to the latest statistics, almost 1 million Ontarians aged 4 years and older have been
diagnosed with asthma (Statistics Canada, 2000). A significant increase in the prevalence of asthma
in Ontario has occurred in recent years – from 7.4% of those aged 4 and older in 1994/95 to
24
8.9% in 1998/99 (Statistics Canada, 2000).
Although most people with asthma can achieve good asthma control, many do not. Many
underestimate the severity and control of their asthma and continue to restrict their everyday
activities, and suffer needlessly. Proper asthma management can lead to better asthma control
and may reduce the incidence of death from asthma by as much as 80% (Institute for Clinical
Evaluative Sciences in Ontario, 1996). These increases in the prevalence of asthma and associated
morbidity and cost are occurring despite advances in our understanding and treatment.
What Is Asthma?
Asthma is a chronic inflammatory disorder of the airways characterized by an increase in
airway responsiveness and airway narrowing, which leads to difficulty in breathing. Asthma
is usually classified as mild, moderate or severe. Although symptoms vary from person to person,
common symptoms include shortness of breath, chest tightness, wheezing, and/or coughing.
Asthma episodes may begin suddenly or may have a slow onset with a gradual worsening of
symptoms. These episodes can last for a few minutes to several days, and are attributed to a
hyperresponsiveness of the airways and are typically reversible (The Lung Association, 2000).
The pathology of an asthma episode is depicted in the figures below. The first illustrates the
normal airway. When individuals with asthma are exposed to triggers that they are sensitive
to, the airway narrows. This narrowing develops in one or two ways:
The airway becomes swollen and plugged with mucous (inflammation), thus making
the airway opening considerably smaller. This is depicted in the middle picture. This
inflammation can last from a few hours to a few days to a lifetime.
The muscles surrounding the airway tighten and go into spasm (bronchospasm). The
picture on the right demonstrates this process.
Normal Airway
Airway Lining
Inflammation
Bronchospasm & Inflammation
Airway Opening
Airway Opening
25
Muscle
Swelling of the airway lining
Inflammation
Muscle tightens causing spasm
Bronchospasm
Bronchoconstriction
Regardless of the person’s asthma severity, any loss of asthma control can potentially be
life-threatening. The goal of asthma care is to control or prevent the airway inflammation
and to minimize the symptoms experienced and interruptions to daily life. Components of
asthma management include education, environmental control measures, appropriate
medications, action plans, establishing a partnership between the client and provider and
regular follow-up care.
Key points
Asthma is a chronic inflammatory disorder of the airways
Typical symptoms include shortness of breath, chest tightness, wheezing
and/or coughing.
Airflow limitation in asthma is reversible.
The severity of an asthma episode can range from mild to
life-threatening and last from minutes to days.
What causes asthma?
Although the exact cause of asthma is not known, several predisposing factors have been
implicated in its development. These include atopy – a greater tendency to have allergic reactions
to environmental allergens (Sporik et al., 1990); genetics – a family history of asthma and/or atopy
(Larsen, 1992; Millar & Hill, 1998); and exposure to environmental tobacco smoke (Arshad, 1992; Cook &
Strachan, 1997; Soyseth, Kongerud & Boe, 1995; Stoddard & Miller, 1995).
There are several triggers that may irritate the hypersensitive airways in people with asthma
and provoke an asthma episode. Common triggers include:
26
a) Irritants such as:
Tobacco smoke (BTS/SIGN, 2003; Boulet et al., 2001, 1999; Chilmonczyk, Salmun & Megathlin, 1993;
GINA, 2002; Murray & Morrison, 1986; Murray & Morrison, 1989; NIH, 1997; NZGG, 2002; United States
Environmental Protection Agency, 1992);
Exercise+ (American Academy of Allergies, Asthma, and Immunology et al., 1999; Boulet et al., 1999; GINA,
2002; NZGG, 2002);
Exposure to work-related agents or indoor chemicals (American Academy of Allergy, Asthma,
and Immunology et al., 1999; Boulet et al., 1999; Egan, 1985; GINA, 2002; NIH, 1997; NZGG, 2002; Packe,
Archer & Ayres, 1983; Salvaggio et al., 1970; Usetti et al., 1983; Virchow et al., 1988); and
Outdoor pollutants (BTS/SIGN, 2003; Boulet et al., 1999; Burnett et al., 1995; Cody, Weisel, Birnbaun & Lioy,
1992; Delfino, 1994; GINA, 2002; Hoek & Brunekreef, 1995; NIH, 1997; NZGG, 2002; Pope, 1989; Pope, 1991;
Rennick & Jarman, 1992; Roemer, Hock & Brunekreef, 1993; Schwartz, Slater, Larson, Pierson & Koenig, 1993).
b) Allergens such as:
Pollen (GINA, 2002; NZGG, 2002; Peat et al., 1993; Suphioglu et al., 1992);
Moulds (GINA, 2002; Hide et al., 1994; NIH, 1997; Zacharasiewicz et al., 1999);
Dust mites (BTS/SIGN, 2003; Boulet et al., 2001; Chapman, Heymann, Wilkins, Brown & Platts-Mills, 1987;
GINA, 2002; Kuehr et al., 1995; Marks et al., 1995; NIH, 1997; NZGG, 2002; Platts-Mills, Hayden, Chapman &
Wilkins, 1987);
Pet dander (BTS/SIGN, 2003; Boulet et al., 2001; Gelber et al., 1993; GINA, 2002; Kuehr et al., 1995;
Millar & Hill, 1998; NIH, 1997; NZGG, 2002; Pollart, 1989; Sears et al., 1993; Sporik et al., 1995;
Strachan & Carey, 1995; Warner et al., 1990);
Foods or food additives (Freedman, 1977; GINA, 2002; Lee, 1992; NZGG, 2002; Taylor, Sears & van
Herwaarden, 1994); and
Cockroach allergen (Boulet et al., 2001; GINA, 2002; NIH, 1997; Rosenstreich et al., 1997).
+ Despite its potential to be a trigger, with a proper warm up, people with exercise-induced asthma should
be able to engage in physical activity (Boulet et al., 1999).
c) Other factors that can trigger or worsen asthma severity:
Upper respiratory/viral infections (Boulet et al., 1999; GINA, 2002; Lemanske, 1989; NIH, 1997;
NZGG, 2002; Pattemore, Johnston & Bardin, 1992);
Rhinitis/Sinusitis (Boulet et al., 1999; Corren, Adinoff, Buchmeir & Irvin, 1992; GINA, 2002: Watson,
Becker & Simons, 1993);
Gastroesophageal reflux (GINA, 2002; Irwin et al., 1989; NIH, 1997; Nelson, 1984);
Sensitivity to aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDS) (GINA,
2002; NIH, 1997; NZGG, 2002; Settipane et al., 1995; Szczeklik & Stevenson, 1999; Sampson, 1999); and
Topical and systemic beta-blockers (GINA, 2002; NIH, 1997; Odeh, Olivern & Bassan, 1991;
Schoene, Abuan, Ward & Beasley, 1984).
Some individuals with asthma may react to only one trigger, others may react to several.
Further, an individual’s triggers may change over time. It is important for individuals with
asthma to know their triggers and the appropriate steps to reduce exposure (Ministry of Health
and Long-Term Care, 2000).
Key points
Common asthma triggers include irritants, allergens, and viral infections.
Allergic rhinitis, sinusitis or gastroesophageal reflux may aggravate asthma.
An individual’s triggers may change over time.
Prevalence and Impact of Asthma
In Ontario, it is estimated that almost 1 million people (8.9% of the population) over the age
of four have asthma (Statistics Canada, 2000). Further, asthma is implicated in at least 155 deaths
per year in Ontario (Ministry of Health and Long-Term Care, 2000). An Australian study reported that
45% of people who died from their asthma had been assessed as having mild or moderate
asthma (Robertson, Rubinfeld & Bowes, 1990).
Despite medical advances in understanding the disease and the availability of more effective
medications, poorly controlled asthma is a significant problem. According to a 2000 national
survey (Chapman et al, 2001), more than 6 in 10 individuals with asthma (62%) are poorly controlled
– that is, they experienced at least two of the following: daytime symptoms, sleep disturbances,
physical activity restrictions, asthma episodes, absenteeism from work or school, and excess
use of rescue medication. Similar estimates have been reported for Ontario (Health Canada, 1998).
27
Our healthcare system is bearing a significant burden in terms of hospitalizations and
emergency room visits as a result of poorly controlled asthma. According to the National
Population Health Survey 1996-1997 (Statistics Canada, 2000) 18% of people with asthma had
visited the emergency department at least once in the past year. In Ontario, 65,109 days spent
in hospital were attributed to poorly controlled asthma, costing the healthcare system
$44,432,300 (Statistics Canada, 2000). These costs do not factor in other direct costs of the illness,
such as physician visits and costs of medications, nor indirect costs, such as disability,
absence from school or work, costs related to premature deaths, and traveling expenses to
and from hospital. Although total figures for Ontario have not been tabulated, a 1995/1996
study to assess the annual cost of asthma in adult clients in south central Ontario concluded
28
that the unadjusted annual costs were $2,550 per client (Ungar, Coyte, Chapman & MacKeigan, 1998).
Multiplying this estimate by approximately 1 million asthmatics in Ontario, it is estimated
that over 2.5 billion dollars per year is spent in Ontario on asthma management.
The burden of poorly controlled asthma for the individual is difficult to estimate since a
significant number of cases may go unreported and/or undiagnosed. In Ontario, 31% of
individuals with asthma reported missing school, work, and/or social functions due to their
asthma (ICES, 1996). Even if the individual with asthma is able to attend work or school,
ongoing symptoms or medication may alter concentration and performance (National Asthma
Control Task Force, 2000).
Key Points
Almost 1 million people in Ontario have been diagnosed with asthma.
6 in 10 individuals with asthma are poorly controlled.
Asthma is implicated in 155 deaths per year in Ontario.
Most asthma related deaths are preventable.
Annual costs in Ontario for asthma may be as high as 2.5 billion
dollars per year.
Gaining Control Over Asthma
Reducing the burden of asthma requires a greater understanding of why the prevalence of
poorly controlled asthma is so high. Despite a high prevalence of uncontrolled asthma,
Chapman et al. (2001) noted that most clients (91%) believe that their asthma is adequately
controlled, while only 24% of those studied achieved disease control by meeting the six
symptom-based criteria listed by the Canadian Asthma Consensus Report (1999). One-half
(48%) of patients with poorly controlled asthma who used inhaled steroids did not
understand the role of inhaled steroids and one-third (32%) of patients with poorly
controlled asthma who used short acting bronchodilators misunderstood the action of quick
relief bronchodilators.
The study concluded that people with asthma have:
low expectations about their asthma control;
a poor understanding of the role of various medications; and
learned to live with and tolerate symptoms and limitations that are generally avoidable.
In addition, the survey highlighted that physicians were no better than their clients with
asthma regarding the perception of asthma control (Chapman et al., 2001).
Proper care of asthma including education, environmental control measures, appropriate
medications, action plans and regular follow-up care leads to optimal asthma control,
improved quality of life for individuals with asthma and reduces the burden of healthcare
costs. Because nurses are in contact with clients with asthma in a multitude of settings, they
are in a unique situation to promote asthma control, identify early indicators of poorly
controlled asthma, positively influence self-care practices and facilitate the referral of
individuals to community resources and specialized care.
Key Points
Most individuals with asthma accept poorly controlled asthma as normal
or do not recognize that their asthma is out of control.
Many physicians are not aware when their clients’ asthma is out of control.
Best Practice Guidelines for nurses are needed to improve understanding
and management of asthma.
29
Practice Recommendations
Assessment of Asthma Control
Recommendation • 1.0
All individuals identified as having asthma, or suspected of having asthma, will have their
level of asthma control determined by the nurse.
30
Every client should be screened to identify those most likely to be affected by asthma. As
part of the basic respiratory assessment, nurses should ask every client two questions:
Have you ever been told by a physician that you have asthma?
Have you ever used a puffer/inhaler or asthma medication for breathing problems?
(Level IV)
For individuals identified as having asthma or suspected of having asthma, the level of
asthma control should be assessed by the nurse. Nurses should be knowledgeable about the
acceptable parameters of asthma control, which are:
use of inhaled short-acting ß2 agonist < 4 times/week (unless for exercise);
experience of daytime asthma symptoms < 4 times/week;
experience of night time asthma symptoms < 1 time/week;
normal physical activity levels;
no absence from work or school; and
infrequent and mild exacerbations. (Level IV)
Indicators of Acceptable Asthma Control
Parameter
Frequency/Value
Daytime symptoms
< 4 times/week
Night-time symptoms
< 1 time/week
Need for short-acting ß2 agonist
< 4 times/week
Physical activity
Unaffected
Exacerbations
Mild, infrequent
Work/school absence
None
FEV1 or PEF rate
> 85% personal best
PEF diurnal variation
< 15% variation
Adapted from Canadian Asthma Consensus Report (1999, 2001)
If any one parameter exceeds the described frequency/value, then the client may have
uncontrolled asthma.
For individuals identified as potentially having uncontrolled asthma, the level of acuity
needs to be assessed by the nurse and an appropriate medical referral provided, i.e., urgent
care or follow-up appointment. (Level IV)
Indicators for Immediate Medical Attention
The following criteria should be assessed and supplemented by spriometry, if available
(BTS/SIGN, 2003; NZGG, 2002; SIGN, 1999):
respiration rate greater than 25 breaths/min (Level III);
pulse greater than 110 beats/min (Level III);
accessory muscle use (Level III);
unable to complete a sentence between breaths (Level III);
person is distressed (fatigue, exhaustion) and agitated (if person says they are in trouble
or anxious, or have an impending sense of doom) (Level III);
confusion (Level III); and
altered level of consciousness (Level III).
If the client exhibits any one of the above symptoms, then they should be referred for immediate
medical attention.
31
Discussion of Evidence
Several sources confirm an epidemic of poorly controlled asthma (Chapman et al., 2001; Health
Canada, 1998; Statistics Canada, 2000). It is essential that individuals at risk of having poorly
controlled asthma be identified and their asthma control assessed (Boulet et al., 1999). If any one
of the indicators for immediate medical attention is present, clients may be at increased risk
of dying (BTS/SIGN, 2003; NZGG, 2002; SIGN, 1999). See Appendix C for individual questions to assess
level of asthma control, and a flow-chart of the process.
Note: It is important to mention that the initial screening questions recommended in the
respiratory assessment to identify individuals with asthma or at risk of having asthma may
32
also identify those with or at risk of having Chronic Obstructive Pulmonary Disease (COPD).
The initial assessment questions are not meant to diagnose or differentiate between asthma
and COPD. Establishing the diagnosis of COPD and/or asthma requires pulmonary function
testing and cannot be based on history alone. Asthma and COPD can present similarly in
terms of symptom experience (cough, dyspnea, shortness of breath) and medications used
to manage the conditions (bronchodilators and corticosteroids). In addition, individuals can
have both asthma and COPD, causing diagnostic confusion for clients and clinicians.
Asthma Education
Asthma education, provided by the nurse, must be an essential component of care.
The client’s asthma knowledge and skills should be assessed and where gaps are identified,
asthma education should be provided. (Level I)
basic facts about asthma;
roles/rationale for medications;
device technique(s);
self-monitoring; and
action plans. (Level IV)
Basic facts about asthma
normal versus asthmatic airways;
what happens during an asthma episode;
signs and symptoms of control; and
identification and reduction of triggers.
Roles/rationale for medications (see Appendix D and J)
when to use reliever (short-term relief) versus controller (long-term control); and
importance of adherence to prescribed medication.
Device technique(s) (see Appendix E, H and I)
good inhaler technique;
use of spacer; and
peak flow technique and monitoring (optional).
Self-monitoring and action plan (see Appendix F and G)
what it is and how to use it.
A number of controlled trials and systematic reviews with and without meta-analysis have
consistently demonstrated that asthma education programs improve asthma morbidity and
quality of life and reduce healthcare utilization. Asthma education can also be cost effective
(Allen, Jones, & Oldenburg, 1995; Bailey et al., 1990; Bolton et al., 1991; Clark & Nothwehr, 1997; Clarke et al., 1986;
Côté et al., 2001; Devine, 1996; Fireman et al., 1981; Garrett et al., 1994; Gibson et al., 2003; Hindi-Alexander & Cropp.,
1984; Ignacio-Garcia & Gonzalez-Santos, 1995; Lewis et al., 1984; Trautner et al., 1993; Windsor et al., 1990).
The effectiveness of the specific components of asthma education programs has not been
empirically established. However, recommendations from practice guidelines and the literature
indicate that basic education should include: facts about asthma, signs and symptoms
of worsening asthma, self-monitoring strategies, action plan use, information regarding
medications and use of devices (BTS/SIGN, 2003; Boulet et al., 1999; Cicutto et al., 1999; Flaum, Lum Lung &
Tinkleman, 1997; GINA, 2002; Gibson et al., 2003; NZGG, 2002).
Comprehensive education programs that include strategies of self-management, regular
medical supervision and written action plans are associated with better asthma outcomes
than programs offering information only (Gibson et al., 2003). Asthma education programs need
to use a diverse range of educational strategies and methods (Boulet et al., 1999). Wilson et al.
33
(1993), in a controlled trial evaluating two forms of asthma self-management education for
adults, reported that education provided in groups or individual counseling both showed
significant benefits but no difference in outcomes. The group sessions tended to be more
cost effective.
Patient adherence is an important factor in the effectiveness of treatment regimes for any
chronic illness (Baudinette, 2000). Evidence suggests that non-adherence with medication and
treatment plans is a serious problem among people with asthma (Rand, 1998). As many as fifty
percent of people with asthma don’t follow their prescribed treatment – even individuals who
have some understanding of appropriate management strategies have difficulty with adherence
34
(Kolbe et al, 1996). Refer to Appendix J for tips related to improving adherence.
Action Plans
Every client with asthma should have an individualized asthma action plan for guided
self-management based on evaluation of symptoms with or without peak flow
measurement, developed in partnership with a healthcare professional. (Level I)
For every client with asthma, the nurse needs to assess for use and understanding of the
asthma action plan. If a client does not have an action plan, the nurse needs to provide a
sample action plan, explain its purpose and use, and coach the client to complete the plan
with his/her asthma care provider. (Level V)
Where deemed appropriate, the nurse should assess, assist and educate clients in measuring
peak expiratory flow rates. A standardized format should be used for teaching clients how
to use peak flow measurements. (Level IV)
The Canadian Asthma Consensus Report (Boulet et et al., 1999, 2001), along with other national
and international guidelines, recommend that every individual with asthma be provided with
a written action plan (BTS/SIGN, 2003; Boulet et al., 1999, 2001; GINA, 2002; NIH, 1997; SIGN, 1998; NZGG, 2002).
It is the role of the nurse to facilitate the attainment and effective use of an individualized
action plan developed in partnership with the physician and the rest of the asthma care team.
This recommendation is based on a substantive amount of evidence. A Cochrane review
(Gibson et al., 2003) concluded that self-management programs for adults with asthma that
involved self-monitoring, either by peak flow or symptoms, combined with a written action
plan and regular medical review resulted in reduced health services use, days lost from work,
and episodes of nocturnal asthma. It is noteworthy that the programs that included a
written action plan consistently demonstrated benefit whereas those that did not include a
written action plan did not always demonstrate benefit. Recently, a case control study was
published that reported a 70% reduction in the risk of death for individuals who possessed
written action plans (Abramson et al., 2001).
Refer to Appendix F for details about action plans, Appendix G for sample action plans, and
Appendix H and I for details regarding the use of Peak Flow Meters.
Peak Flow versus Symptom Monitoring
Studies comparing peak flow monitoring with self-monitoring of symptoms have reported
little difference in various asthma outcomes (Charlton, Charlton, Broomfield, & Mullee, 1990; Gibson,
Coughlan, Abramson, 1998; Turner, Taylor, Bennett, & Fitzgerald, 1998). However, much debate has focused
on the desired method for self-monitoring, specifically peak expiratory flow (PEF) monitoring
versus symptom monitoring only. Peak flow measurements provide an objective measurement
of lung function, but such measurements have limitations. Côté et al. (1998) have
demonstrated that individuals with asthma have difficulty sustaining daily performance and
recording of peak flow use. There is also a risk of inaccurate readings resulting from poor
technique, misinterpretation of results or device failure (Boulet et al., 1999). Further, several
research findings indicate that changes in peak flow are less sensitive than deterioration of
symptoms during acute episodes of asthma (Chan-Yeung et al., 1996; Gibson et al., 1990; Malo,
L’Archeveque, Trudeau, d’Aquino & Cartier, 1993). A role for action plans based on the regular measurement
35
of PEF, however, is suggested in clients who have difficulty recognizing the severity of their
symptoms (i.e., ‘poor perceivers’), those with very severe asthma, or those recently requiring
emergency department use or hospitalization (Boulet et al., 1999). The choice of peak flow or
symptom monitoring may be based on asthma severity, the client’s ability to perceive airflow
obstruction, the availability of peak flow meters and, most importantly, client preferences
(Boulet et al., 1999; NIH, 1997).
Medications
36
Nurses will understand and be able to discuss with clients their medications.
Nurses will understand and be able to discuss the two main categories of asthma medications
(controllers and relievers) with their clients. (Level IV)
Knowledge of medications includes the following:
trade and generic names;
indications;
doses;
side effects;
mode of administration; and
pharmacokinetics.
All asthma clients should have their inhaler/device technique assessed by the nurse to
ensure accurate use. Clients with sub-optimal technique will be coached in proper
inhaler/device use. (Level I)
Many barriers exist regarding the use of medications that prevent people with asthma from
adequately controlling their disease. These include possible knowledge deficits regarding
the relationship between asthma symptoms and the mechanism of action of asthma
medications, inadequate device technique, the complexity of the medication regime, and
negative feelings toward taking medication daily. In order to address some of these barriers,
the nurse and individual with asthma should be knowledgeable regarding the general
classifications of medications, their indications, actions, side effects, usual doses, and
administration techniques (Boulet et al., 1999).
Medications used to treat asthma can generally be divided into two categories, controllers
(preventers) and relievers. They are available in various forms and are delivered through
a variety of devices. The inhaled route is the preferred route as it minimizes systemic
availability and therefore minimizes side effects (BTS/SIGN, 2003; Boulet et al., 1999; GINA, 2002; NZGG,
2002; NIH, 1997; Newhouse & Dolovich,1986). Appendix D provides a detailed description of controllers
(preventers) and relievers.
Referrals
The nurse will facilitate referrals as appropriate.
Clients with poorly controlled asthma should be referred to their physician. (Level II)
All clients should be offered links to community resources. (Level IV)
Clients should be referred to an asthma educator in their community, if appropriate and
available. (Level IV)
37
Clients may need to be referred to a specialist through their physician if their diagnosis is in
doubt or their asthma is not under control (BTS/SIGN, 2003; Boulet et al., 1999; GINA, 2002; Green et al.,
2000; NIH, 1997; NZGG, 2002; SIGN, 1998). Evidence suggests asthma is better managed when
individuals receive care supplemented by specialists or asthma clinics (BTS/SIGN, 2003; Bartter et al.,
1996; Cicutto et al., 2000; Jin et al., 2000; NZGG, 2002; Volmer et al., 1997) as clients are more likely to receive
objective lung function measurements, anti-inflammatory therapy, asthma education and
regular follow-up care.
38
Education Recommendations
Nurses working with individuals with asthma must have the appropriate knowledge
and skills to:
identify the level of asthma control;
provide basic asthma education; and
conduct appropriate referrals to physician and community resources. (Level IV)
Specific areas of knowledge and skills include the following:
assessment of asthma control;
effective teaching and communication strategies;
assessment for gaps in knowledge and skills;
basic components of asthma education;
asthma medications (see Appendix D);
inhaler/device technique (see Appendix E);
purpose for, and the general structure of, an asthma action plan (see Appendix F and G);
use of peak flow monitoring (see Appendix H and I); and
available community resources (see Appendix K and L).
Individuals with asthma need regular supervision and support by healthcare professionals
who are knowledgeable about asthma and its management (BTS/SIGN, 2003; Boulet et al., 1999; GINA,
2002; NZGG, 2002). In order to provide the necessary support and education to adults with asthma,
nurses who are not specialists in asthma care require basic skills in these identified areas.
Education of healthcare providers about asthma best practices should address the knowledge,
skill and attitudes necessary to implement the guideline recommendations (NZGG, 2002).
All healthcare professionals working with adults with asthma require basic education, which
should include: the content of the clinical practice guidelines; information about asthma;
prevention of exacerbations; training in guided self-management; ability to recognize
deteriorating asthma; knowledge about medications; training in the proper use of medication
inhalers/devices and peak flow meters. This education should emphasize the importance of
preventive management. In addition, healthcare professionals need to recognize that patient
education involves giving information and assisting with the acquisition of skills, as well as
behaviour change on the part of the individual with asthma. This component of successful
client education requires strong communication skills on the part of the provider (GINA, 2002).
Organization &
Policy Recommendations
Organizations should have available placebos and spacer devices for teaching, sample
templates of action plans, educational materials, and resources for client and nurse
education and where indicated, peak flow monitoring equipment. (Level IV)
Organizations must promote a collaborative practice model within an interdisciplinary
team to enhance asthma care. (Level IV)
39
Organizations need to ensure that a critical mass of health professionals are educated
and supported to implement the asthma best practice guidelines in order to ensure
sustainability. (Level V)
Agencies and funders need to allocate appropriate resources to ensure adequate staffing
and a positive healthy work environment. (Level V)
40
Nursing best practice guidelines can be successfully implemented only when there are
adequate planning, resources, organizational and administrative support, and appropriate
facilitation. Organizations may develop a plan for implementation that includes:
An assessment of organizational readiness and barriers to education.
Involvement of all members (whether in a direct or indirect supportive function)
who will contribute to the implementation process.
Dedication of a qualified individual to provide the support needed for the
education and implementation process.
Ongoing opportunities for discussion and education to reinforce the importance
of best practices.
Opportunities for reflection on personal and organizational experience in
implementing guidelines.
In this regard, RNAO (through a panel of nurses, researchers and administrators) has
developed the Toolkit: Implementation of Clinical Practice Guidelines based on available
evidence, theoretical perspectives and consensus. The Toolkit is recommended for
guiding the implementation of Adult Asthma Care Guidelines for Nurses – Promoting
Control of Asthma. (Level IV)
Refer to Appendix M for a description of the Toolkit.
Evaluation & Monitoring
Organizations implementing the recommendations in this nursing best practice guideline
are advised to consider how the implementation and its impact will be monitored and
evaluated. The following table, based on the framework outlined in the Toolkit: Implementation
of Clinical Practice Guidelines (2002), summarizes some suggested indicators for monitoring
and evaluation:
Level of Indicator
Structure
Process
Outcome
• To evaluate the supports
available in the organization
that allow for nurses to
promote control of asthma.
• To evaluate changes in
practice that lead towards
improved control of asthma.
• To evaluate the impact
of implementing the
recommendations.
Organization
• Availability of client
education resources (sample
action plans, referral
information) that are
consistent with best practice
guideline recommendations.
• Access to placebos (e.g.,
MDIs, Turbuhaler®, Diskus®),
holding chambers (spacers)
and peak flow meters for
client education.
• Review of best practice
guideline recommendations
by organizational committee(s)
responsible for policies or
procedures.
• Availability of, and access to,
asthma specialists.
• A standardized tool is used to
assess asthma control.
• Policies and procedures
related to assessing asthma
control are consistent with
the guidelines.
Nurse
• Availability of educational
opportunities related to
promoting asthma control
within the organization.
• Number of nurses attending
educational sessions related
to promoting asthma control.
• Level of asthma control
assessed, including:
• inhaled short acting ß2 use;
• night time awakenings;
• daytime symptoms;
• interruption with daily
activities.
• Nurses’ self-assessed knowledge of:
• asthma control criteria;
• two main categories of
asthma medication;
• correct inhaler/device
technique;
• asthma action plans; and
• available educational
materials and community
resources.
• Evidence of documentation
in client record consistent
with guideline
recommendations regarding:
• assessment of asthma
control;
• assessment of inhaler/
device technique;
• provision of asthma
education;
• review of action plan;
• referral to asthma educator,
asthma clinic or other
community resource.
41
Level of Indicator
Structure
Client
42
Financial Costs
Process
Outcome
• Percent of clients reporting
that their asthma control was
assessed.
that the nurse reviewed the
use and importance of an
action plan.
that a nurse asked them to
demonstrate the use of their
inhaler/device.
• Percent of clients with
acceptable asthma control.
action plans.
• Percent of clients judged
to have satisfactory device
technique.
• Percent of clients admitted
to emergency department or
hospital in one year with
asthma related symptoms.
documented lung function
measurements PEF and/or
FEV1 recorded.
• Provision of adequate
financial and human
resources for guideline
implementation.
Examples of evaluation tools that were used to collect data on some of the indicators
identified above during the pilot implementation/evaluation of this guideline are available
at www.rnao.org/bestpractices.
Implementation Tips
This best practice guideline was pilot tested at Trillium Health Centre, a large two site acute
care community-based hospital serving south Mississauga and Etobicoke, Ontario. The lessons
learned and results of the pilot implementation may not be appropriate to generalize to other
settings. However, there were many strategies used that the pilot site found helpful during
implementation. Those who are interested in implementing this guideline may wish to
consider these tips. A summary of these strategies follows:
Communicating and raising awareness of asthma and the best practice guideline
is critical. Consider having a project launch, use your agency’s newsletter, or create
a project news bulletin.
Remember to set small incremental goals and to celebrate achieving your milestones.
Consider “branding” your project with a logo or other form of identification – this logo
can be used on all memos, posters and printed material to help identify and heighten
project awareness around the organization.
Transfer strategies that were helpful in nursing education included:
The development of clinical area specific education sessions. For example, content
was tailored specifically for the nurses of the emergency department, inpatient units
and outpatient clinics.
The development of a patient pathway (see Appendix N) and two different
documentation tools for the emergency and in-patient departments allowed the
nurses to target their assessment and teaching to the client’s needs. This reduced
duplication of nursing workload.
Pre-learning packages allowed nurses to familiarize themselves with some of the
content prior to attending the educational sessions. This reduced the amount of
content to be covered in the class, and allowed for more active involvement by
participants in the session. The packages also acted as a source for a “refresher”
after the sessions were complete.
A train-the-trainer approach proved to be helpful. After nurses received their
education, they wore the project logo (a stoplight) on their name tag to identify
themselves as someone that had completed their education and could act as a
resource person to assist with patient teaching.
Once the initial education session was complete, the nurses facilitating the project
implementation booked time on the nursing units to conduct short 15 minute
review “in-services”. These refresher sessions used games and activities to help the
nurses review their skills with medication devices, drug categories, and the use of
a patient teaching booklet.
Patient teaching resources were placed in each of the clinical areas. These resources
contained teaching tools such as medication placebos, patient education booklets
and other materials that a nurse would need to teach clients and families.
In addition to the tips mentioned above, RNAO has published implementation resources that
are available on the website. A Toolkit for implementing guidelines can be helpful, if used
appropriately. A brief description about this Toolkit can be found in Appendix M. It is available
for free download at www.rnao.org/bestpractices. Implementation resources developed by
the pilot site are also available on the website to assist individuals and organizations implement
this best practice guideline. These resources are specific to the pilot site, and have been made
available as examples of local adaptation for guideline implementation.
43
Process For Update/Review
of Guideline
The Registered Nurses Association of Ontario
proposes to update the Best
Practice Guidelines as follows:
1. Following dissemination, each nursing best practice guideline will be reviewed by a team of
specialists (Review Team) in the topic area every three years following the last set of revisions.
44
2. During the three-year period between development and revision, RNAO Nursing
Best Practice Guideline project staff will regularly monitor for new systematic reviews,
meta-analysis papers and randomized controlled trials (RCTs) in the field.
3. Based on the results of the monitor, project staff may recommend an earlier revision
period. Appropriate consultation with a team comprised of original panel members and
other specialists in the field will help inform the decision to review and revise the best
practice guideline earlier than the three year milestone.
4. Three months prior to the three year review milestone, the project staff will commence
planning of the review process as follows:
a) Invite specialists in the field to participate in the Review Team activities. The
Review Team will be comprised of members from the original panel as well as other
recommended specialists.
b) Compilation of feedback received, and questions encountered during the dissemination
phase as well as other comments and experiences of implementation sites.
c) Compilation of new clinical practice guidelines in the field, systematic reviews,
meta-analysis papers, technical reviews and randomized controlled trial research.
d) Develop a detailed work plan with target dates for deliverables.
The revised guideline will undergo dissemination based on established structures and processes.
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Therapeutics Initiative, The (1996, January).
Changing concepts in the management of asthma.
The Therapeutics Initiative, 1-4.
Town, G. I., Hodges, I. D., Wilkie, A. T., Toop,
L. J., Graham, P., & Drennam, C. J. (1995).
A community-wide promotion of asthma selfmanagement in New Zealand. Patient Education
and Counseling, 26(1-3), 219-224.
Ungar, W., Chapman, K., & Santos, M. (2002).
Assessment of a medication-based asthma
index for population research. American Journal
of Respiratory and Critical Care Medicine, 165(2),
190-194.
van der Palen, J., Klein, J., & Seydel, E. R. (1997).
Are high generalised and asthma-specific
self-efficacy predictive of adequate selfmanagement behaviour among adult asthma
patients? Patient Education and Counseling,
32(Suppl 1), S35-S41.
van der Palen, J., Klein, J., Zielhuis, G., van
Herwaarden, C. L., & Seydel, E. (2001).
Behavioural effect of self-treatment guidelines
in a self-management program for adults with
asthma. Patient Education and Counseling,
43(2), 161-169.
van der Palen, J., Klein, J. J., & Rovers, M. M.
(1997). Compliance with inhaled medication
and self-treatment guidelines following a
self-management program in adult asthmatics.
European Respiratory Journal, 10(3), 652-657.
Wakefield, M., Ruffin, R., Campbell, D., Staugas,
R., Beilby, J., & McCaul, K. (1997). A risk screening
questionnaire for adult asthmatics to predict
attendance at hospital emergency departments.
CHEST, 112(6), 1527-1533.
White, P. T., Phaorah, C. A., Anderson, H. R., &
Freeling, P. (1989). Randomized controlled trial of
small group education on the outcome on chronic
asthma in general practice. The Journal of the
Royal College of General Practitioners, 39 182.
Wolf, FM., Guevara, J. P., Grum, C. M., Clark, N.
M., & Cates, C. J. (2003). Educational interventions
for asthma in children (Cochrane Review). In The
Cochrane Library, Issue 3. Oxford: Update Software.
Yoon, R., McKenzie, D. K., Bauman, A., & Miles, D.
A. (1993). Controlled trial evaluation of an asthma
education programme for adults. Thorax, 48(11),
1110-1116.
Appendix A: Search Strategy
for Existing Evidence
STEP 1 – Database Search
An initial database search for existing asthma guidelines was conducted in early 2001 by a
company that specializes in searches of the literature for health related organizations,
researchers and consultants. A subsequent search of the MEDLINE, Embase, and CINAHL
databases for articles published from January 1, 1995 to February 28, 2001 was conducted
using the following search terms and key words: “asthma”, “self care”, “self management”,
“practice guideline(s)”, “clinical practice guideline(s)”, “standards”, “consensus statement(s)”,
“consensus”, “evidence-based guidelines”, and “best practice guidelines”. In addition, a
search of the Cochrane Library database for systematic reviews was conducted concurrently using the above search terms.
STEP 2 – Internet Search
A metacrawler search engine (metacrawler.com) plus other available information provided
by the project team was used to create a list of websites known for publishing or storing
clinical practice guidelines. The following sites were searched in early 2001:
Agency for Healthcare Research and Quality: www.ahrq.gov
Alberta Clinical Practice Guidelines Program:
www.amda.ab.ca/general/clinical-practice-guidelines/index.html
American Medical Association: www.ama-assn.org/
Best Practice Network: www.best4health.org
British Columbia Council on Clinical Practice Guidelines:
www.hlth.gov.bc.ca/msp/protoguide/index.html
Canadian Centre for Health Evidence: www.cche.net
Canadian Institute for Health Information (CIHI): www.cihi.ca/index.html
Canadian Medical Association Guideline Infobase: www.cma.ca/eng-index.htm
Canadian Task Force on Preventative Health Care: www.ctfphc.org/
Cancer Care Ontario: www.cancercare.on.ca
Centre for Disease Control: www.cdc.gov
Centre for Evidence-Based Child Health: www.ich.bpmf.ac.uk/ebm/ebm.htm
61
Centre for Evidence-Based Medicine: www.cebm.jr2.ox.ac.uk/
Centre for Evidence-Based Mental Health: www.psychiatry.ox.ac.uk/cebmh/
Centre for Evidence-Based Nursing: www.york.ac.uk/depts/hstd/centres/evidence/ev-intro.htm
Centre for Health Services Research: www.nci.ac.uk/chsr/publicn/tools/
Core Library for Evidence-Based Practice: www.shef.ac.uk/~scharr/ir/core.html
Clinical Resource Efficiency Support Team (CREST): www.n-i.nhs.uk/crest/index.htm
Evidence-based Nursing: www.bm.jpg.com/data/ebn.htm
Health Canada: www.hc-sc.gc.ca
Health Care Evaluation Unit: Health Evidence Application and Linkage Network (HEALNet):
www.healnet.mcmaster.ca/nce
62
Institute for Clinical Evaluative Sciences (ICES): www.ices.on.ca/
Institute for Clinical System Improvement (ICSI): www.icsi.org
Journal of Evidence-Based Medicine: www.bmjpg.com/data/ebm.htm
McMaster University Evidence-Based Medicine site: www.hiru.hirunet.mcmaster.ca/ebm
McMaster Evidence-Based Practice Centre: www.hiru.mcmaster.ca/epc/
Medical Journal of Australia: www.mja.com.au/public/guides/guides.html
Medscape Multispecialty: Practice Guidelines:
www.medscape.com/Home/Topics/multispecialty/directories/dir-MULT.PracticeGuide.html
Medscape Women’s Health:
www.medscape.com/Home/Topics/WomensHealth/directories/dir-WH.PracticeGuide.html
Monash University, Australia (Centre for Clinical Effectiveness)
www.med.monash.edu.au/publichealth/cce/evidence/
National Guideline Clearinghouse: www.guideline.gov/index.asp
National Library of Medicine: www.text.nim.nih.gov/ftrs/gateway
Netting the Evidence: A ScHARR Introduction to Evidence-Based practice on the Internet:
www.shef.ac.uk/uni/academic/
New Zealand Guideline Group: www.nzgg.org.nz/library.cfm
Primary Care Clinical Practice Guidelines: www.medicine.ucsf.educ/resources/guidelines/
Royal College of General Practitioners: www.rcgp.org.uk/Sitelis3.asp
Royal College of Nursing: www.rcn.org.uk
Scottish Intercollegiate Guidelines Network: www.show.scot.nhs.uk/sign/home.htm
TRIP Database: www.tripdatabase.com/publications.cfm
Turning Research into Practice: www.gwent.nhs.gov.uk/trip/
University of California: www.library.ucla.edu/libraries/biomed/cdd/clinprac.htm
www.ish.ox.au/guidelines/index.html
One individual searched each of these sites. The presence or absence of guidelines was noted
for each site searched – at times it was indicated that the website did not house a guideline
but re-directed to another website or source for guideline retrieval. A full version of the
document was retrieved for all guidelines.
STEP 3 – Hand Search/Panel Contributions
Panel members were asked to review personal archives to identify guidelines not previously
identified. In a rare instance, a guideline was identified by panel members and not found
through the database or Internet search. These guidelines were developed by local groups
and had not been published to date. Results of this strategy revealed no additional clinical
practice guidelines.
STEP 4 – Core Screening Criteria
This search method revealed multiple guidelines, several systematic reviews and numerous
articles related to asthma. The final step in determining whether the clinical practice guideline
would be critically appraised was to apply the following criteria:
guideline was in English;
guideline was dated 1995 or later;
guideline was strictly about the topic area;
guideline was evidence-based, i.e., contained references, description of evidence,
sources of evidence; and
guideline was available and accessible for retrieval.
Ten guidelines identified were deemed suitable for critical review using the Cluzeau et al.
(1997) Appraisal Instrument for Clinical Practice Guidelines.
63
TITLE OF THE PRACTICE GUIDELINE RETRIEVED AND CRITICALLY APPRAISED
Alberta Medical Association (1999). Guideline for the management of acute asthma in adults
and children. The Alberta Clinical Practice Guidelines Program. [Online]. Available:
www.albertadoctors.org/resources/cpg/guidelines/acute_asthma.pdf.
Boulet, L. P., Becker, A., Bérubé, D., Beveridge, R., & Ernst, P. (1999). Canadian asthma consensus
report. [Online]. Available: www.cmaj.ca/cgi/reprint/161/11_suppl_1/s1.pdf.
British Thoracic Society (1997). Revised guidelines on asthma management. British Thoracic
64
Society, 12(Suppl. 1), 408-410.
Green, L., Baldwin, J., Grum, C., Erickson, S., Hurwitz, M., & Younger, J. (2000). UMHA asthma
guideline. University of Michigan Health System [Online]. Available: www.guideline.gov.
Institute for Clinical Systems Improvement (2001). Health care guideline: Diagnosis
and management of asthma. ICSI Health Care Guideline. [Online]. Available:
www.ICSI.org/guidelist.htm#guidelines.
National Institutes of Health (1995). Nurses: Partners in asthma care. (No. 95-3308 ed.)
NIH Publication.
National Institutes of Health (1997). Guidelines for the diagnosis and management of asthma
(Rep. No. 2). NIH Publication. [Online]. Available: www.nhlbi.nih.gov/guidelines/
asthma/asthgdln.htm.
Scottish Intercollegiate Guidelines Network (1996). Hospital in-patient management of acute
asthma attacks – SIGN 6. [Online]. Available: www.show.scot.nhs.uk/sign/home.htm.
Scottish Intercollegiate Guidelines Network (1998). Primary care management of asthma – SIGN
33. [Online]. Available: www.show.scot.nhs.uk/sign/home.htm.
Scottish Intercollegiate Guidelines Network (1999). Emergency management of acute
asthma – SIGN 38. [Online]. Available: www.show.scot.nhs.uk/sign/home.htm.
Three additional guidelines were identified and critically appraised during the guideline
revision. These were appraised using the Appraisal of Guidelines for Research and Evaluation
(AGREE) instrument (The AGREE Collaboration, 2001).
British Thoracic Society and the Scottish Intercollegiate Guidelines Network (2003).
British guideline on the management of asthma. [Online]. Available: www.sign.ac.uk/
pdf/sign63.pdf
Global Initiative for Asthma (2002). Global strategy for asthma management and prevention.
[Online]. Available: www.ginasthma.com
New Zealand Guideline Group (2002). Best practice evidence-based guideline: The
diagnosis and treatment of adult asthma. [Online]. Available: http://www.nzgg.org.nz/
library/gl_complete/asthma/full_text_guideline.pdf
65
Appendix B: Glossary of Terms
Agonist:
A substance that mimics, stimulates or enhances the normal physiological
response of the body.
Airway Remodeling:
A collective term that encompasses the alterations in
structural cells and tissues in the airways of some individuals with asthma, which may
or may not be reversible.
Allergen: A protein or non-protein substance that is capable of inducing an allergic
66
reaction or hypersensitivity. Common allergens can include: house dust mites, house dust,
animals, food, mould, and pollen.
Antagonist: A substance that inhibits the normal physiological response of the body.
Asthma Episode: A worsening of asthma symptoms caused by bronchoconstriction,
also referred to as an asthma attack, asthma exacerbation or asthma flare-up, in which the
individual’s asthma is out of control.
Atopy:
Development of an immunoglobulin E (IgE) mediated response to common
allergens.
ß2 Agonist:
A group of bronchodilators resulting in smooth muscle relaxation and
bronchodilation through stimulation of ß2 receptors found on airway smooth muscle.
Bronchoconstriction: A narrowing of the airway caused by bronchial smooth muscle
contraction (tightening) and airway inflammation (swelling).
Bronchodilators: A category of medications that produce relaxation of the smooth
muscles surrounding the bronchi, resulting in dilatation of the airways. See Relievers
Controllers: Controllers are medications that are taken regularly on a daily basis to
minimize asthma symptoms from occurring and prevent exacerbations. They may also be
known as preventers.
Corticosteroids: A group of synthetic hormones that suppress the various inflammatory
processes involved with asthma and are currently the most effective maintenance therapy
for most patients. See Controllers
Dry-Powder Inhaler (DPI): A breath activated device used to deliver medication in
powder form to the lungs.
Forced Expiratory Volume in the first second in liters (FEV1): The measure
of the maximum volume of air a person can breathe out from the lungs in the first second of
a forced expiratory manoeuvre. It is the most important measurement for monitoring
obstructive lung disease and determines the severity of airway obstruction. The normal value
is > 80% of the predicted value. See Spirometry
Hyperresponsiveness: The tendency of the smooth muscle of the airway to contract
more intensely in response to a given stimulus/irritant than it does in a normal airway. This
condition is present in virtually all symptomatic individuals with asthma. The most prominent
manifestation of this smooth muscle contraction is airway narrowing.
Irritants: A class of triggers that are non-allergenic that can provoke asthma symptoms.
Leukotriene-Receptor Antagonists (LTRA): A non-steroidal anti-inflammatory
medication that works by blocking the leukotriene receptors on cells involved in the
inflammatory process.
Metered Dose Inhaler (MDI):
A hand activated device used for delivering an
aerosolized medication to the lungs.
Metered Dose Inhaler, Chlorofluorocarbon Propelled – MDI(CFC):
A metered-dose inhaler using a chlorofluorocarbon as the propellant for aerosolization of
medication.
Metered Dose Inhaler, Hydrofluoroalkane Propelled – MDI(HFA):
A metered-dose inhaler using a hydrofluoroalkane as the propellant for aerosolization of
medication.
67
Nebulizer: A machine that vapourizes medication, using either oxygen or compressed air.
The resulting fine mist is inhaled from either a mask over the nose or a mouthpiece.
Peak Expiratory Flow in L/min (PEF): A measure of the maximum speed at which
a person can forcefully expel air from the lungs following maximal inspiration. It provides a
simple, quantitative and reproducible measure of the existence of airflow obstruction.
The measurement is effort dependent.
Peak Flow Meter (PFM): A portable hand-held device used to measure peak expiratory
flow rate.
68
Preventers: see Controllers
Relievers: Relievers are medications that are used to relieve asthma symptoms and to
prevent asthma symptoms prior to exercise, exposure to cold air or other triggers. See
Bronchodilators; ß2 agonists.
Spacers: A holding chamber device for aerosolized medication that attaches to metereddose inhalers to make it easier to use, and to deliver more medication to the lungs. They are
available in various sizes, with and without masks.
Spirometry: A test that measures forced expiratory volumes and flow rates. See FEV
1
Triggers: Factors that can provoke asthma symptoms. Every individual with asthma has a
unique set of triggers for asthma symptoms. Triggers include both allergens and irritants.
Appendix C: Assessing Asthma Control
Respiratory Screen to Identify those with Asthma
“Have you ever been told by a physician that you have asthma?” OR
“Have you ever used a puffer/inhaler for breathing problems?”
•
•
•
•
YES
NO
Risk of asthma
No further asthma assessment
Assess asthma control
Do you cough, wheeze, or have chest tightness 3 or more times per week?
Do you wake up at night or in the morning with coughing, wheezing
or chest tightness one or more times per week?
Do you use your blue inhaler (reliever medicine) 3 or more times per week
to relieve symptoms (chest tightness, wheeze, cough, dyspnea)?
(excluding use for strenuous exercise)
Have you changed and/or limited your physical activity because of symptoms
(cough, wheeze, chest tightness, SOB) or fear of experiencing symptoms?
69
If YES to one or more,
Asthma is UNCONTROLLED
Urgent medical consultation warranted if ANY of the following exist:
Respiration rate >25 breaths/min
Client is unable to complete a sentence between breaths
Client experiences incomplete relief from, or is unresponsive to,
short acting inhaled ß2 agonist
Client is distressed (fatigue, exhaustion) and agitated (individual says
they are in trouble or anxious or has an impending sense of doom)
Client is confused
NO to all of the above,
uncontrolled and
Non-urgent Care required.
Client displays an altered level of consciousness
YES to any of the above,
uncontrolled and
Urgent Care required
Refer to Physician
Immediate Medical Assistance Required
Provide Education
Once stabilized, Provide Education
•
•
•
•
•
Content of Educational Program
Basic asthma facts
Role/rationale for medications (relievers/controllers)
Device technique
Self-monitoring asthma control
Action plan
Appendix D: Asthma Medications
The Canadian Asthma Consensus Report (1999)
stresses the importance of
using medications at the minimum dose and frequency required to maintain control of
asthma symptoms (Level III). Once control has been established and maintained, physicians
should consider reducing the daily dose of inhaled corticosteroids to the lowest dose necessary
to control symptoms (Level IV). It is important however to recognize that medications are
not to be used as a substitute for proper control of environmental factors, as persistent
exposure to inflammatory triggers will require higher doses of medication to control asthma
symptoms (Level III).
70
People with asthma frequently search for complementary therapies to treat their asthma.
Whether these treatments are used solely or as adjuvant, there is insufficient evidence
demonstrating clinical benefit from complementary therapies (homeopathy, chiropractic,
acupuncture, hypnosis and relaxation techniques, herbal medicine as well as Chinese,
Japanese and Indian medicines) (Level I or II, depending on the therapy).
Medications used to treat asthma can generally be divided into two categories: relievers and
controllers. They are available in various forms and are delivered through a variety of devices,
however, the inhaled route is the preferred route as it minimizes systemic availability and
therefore minimizes side effects (Level I).
a) Relievers
Relievers are medications that are used primarily on an as-needed basis to relieve
asthma symptoms. They may also be used to prevent asthma symptoms prior to
exercise or other triggers.
They are best represented by short-acting ß2-agonists i.e., salbutamol and terbutaline.
Recently, the long-acting ß2-agonist Oxeze (formoterol) was approved for relief of
acute bronchoconstriction.
Relievers are to be used at the lowest dose and frequency required to relieve symptoms.
Daily use of a short acting reliever for symptom control indicates that a controller
(anti-inflammatory) medication is required (Level I). This does not include one dose per
day to prevent exercise-induced bronchospasm.
Ipratropium bromide is less effective than short-acting ß2-agonists and is not
recommended as first line therapy. It may be used as a reliever when short-acting
ß2-agonists are not well tolerated due to side effects (Level III).
Use of an MDI with spacer is preferred over the use of a nebulizer for all clients of
all ages at all levels of severity (Level I).
For emergency situations, ß2-agonists should be administered by inhalations
and titrated using objective and clinical measures of airflow obstruction as dosage
guides (Level I).
In cases of acute asthma, the recommended dosage for ß2-agonists is: 4 to 8 puffs
every 15-20 minutes. However, it may be necessary to increase the dose to 1 puff
every 30-60 seconds (Level IV).
Once maximum relief is achieved, continued administration of bronchodilators
by any route is not likely to provide further clinical benefit and may result in toxic
effects (Level IV).
b) Controllers (preventers)
Controllers are medications that are taken regularly on a daily basis to minimize
asthma symptoms from occurring and to prevent exacerbations.
Controllers are best represented by corticosteroids (inhaled and oral), a potent
anti-inflammatory agent, and are considered the most effective medication in this
category (Level I).
Corticosteroids
Early initiation of treatment with inhaled corticosteroids, in the natural history of the
disease, is associated with a better functional outcome (Level III).
Initial daily dose in adults is commonly in the range of 400-1000µg of beclomethasone
or equivalent. Higher doses of inhaled or the addition of oral or systemic corticosteroids
may be required if the asthma is more severe (Level III).
When asthma is out of control, it should be treated as soon as possible to prevent
a severe exacerbation (Level III). This can be done with a 2 to 4-fold increase in inhaled
corticosteroids (Level IV), or prednisone 0.5 to 1.0 mg/kg a day (Level I) as directed
by a physician.
71
Other anti-inflammatories
Other anti-inflammatory medications in the controller category that are non-steroidal
include: leukotriene-receptor antagonists and anti-allergic agents (sodium cromoglycate
and nedocromil).
Non anti-inflammatories
Other medications are also included in the controller category. These include
long-acting ß2-agonists (salmeterol and formoterol), leukotriene-receptor antagonists
theophylline, and ipratropium bromide. When additional therapy is required to
control asthma symptoms, long-acting ß2-agonists are the primary choice (Level I).
72
Long-acting ß2-agonists assist corticosteroids in achieving and maintaining asthma
control (Level II). Because they mask the underlying airway inflammation, long-acting
ß2-agonists must be used in conjunction with inhaled corticosteroids (Level II).
Leukotriene-receptor antagonists may be an alternative to increasing inhaled
corticosteroids (Level III), but are not recommended as replacement therapy for
inhaled corticosteroids.
Newer therapies such as long-acting ß2-agonists and leukotriene-receptor antagonists have
been shown to be effective second line therapy in the management of asthma (Level II).
Leukotriene-receptor antagonists may be an alternative to increasing inhaled corticosteroids
(Level III), but are not recommended as first line anti-inflammatory therapy in place of inhaled
corticosteroids. They may, however, be used when a person with asthma cannot or will not
use inhaled corticosteroids (Level IV).
Nurses need to be knowledgeable about the various medications within each category
(Level IV). Knowledge of medications includes the following:
trade and generic names;
indications;
doses;
side effects;
mode of administration; and
pharmacokinetics.
Medications
• Atrovent® MDI 20µg,
• Atrovent® Wet Nebulization 125µg and 250 µg/ml
ipratropium bromide
Anticholinergic:
• Berotec® MDI 100µg
• Berotec® vials Wet Nebulization 0.25 mg/ml, 0.625 mg/ml
fenoterol
®
• Bricanyl Turbuhaler PD 500µg
®
Airomir® MDI (HFA) 100µg
Apo-Salvent® MDI(CFC) 100µg
Novo-salmol® MDI(CFC) 100µg
Ventolin® Diskus® PD 200µg
Ventolin® MDI(HFA) 100µg
Ventolin® Nebuamp® Wet Nebulization 1.25 or 2.5 mg
terbutaline
•
•
•
•
•
•
salbutamol
Short acting ß2 agonists:
Relievers
PD – Powder Device
Onset of action:
5-15 minutes
Peaks: 1-2 hours
Duration: 4-5 hours
• An anticholinergic drug
that has been shown
to have bronchodilator
properties
• Reduces vagal tone to the
airways
Onset of action: a few
minutes
Peaks: 15-20 minutes
Duration: 2-4 hours,
fenoterol up to 8 hours
• Promotes bronchodilation
through stimulation of
ß2-adrenergic receptors
thereby relaxing airway
smooth muscle
Actions
MDI(HFA) – Metered dose inhaler, hydrofluoroalkane propelled
tremor
tachycardia
headache
nervousness
palpitations
insomnia
• dry mouth
• bad taste
• tremor
•
•
•
•
•
•
Side Effects
Absorption: minimal
Distribution: does not cross
blood-brain barrier
Metabolism: liver, minimal
Excretion: urine, feces
Half-Life: 3-5 hrs
ipratropium bromide
Absorption: inhalation, minimal;
incomplete PO
Distribution: unknown
Metabolism: liver, 90%
Excretion: breast milk, kidney 12%
Half-Life: 7 hours
fenoterol
Absorption: partially absorbed (PO),
minimal (inhalation)
Distribution: crosses placenta
Metabolism: liver, gut wall
Excretion: bile, feces, urine, breast milk
Half-Life: unknown
terbutaline
Absorption: 20% inhaled, well
absorbed (PO)
Distribution: 30% inhaled, crosses
blood-brain barrier, crosses placenta
Metabolism: liver extensively, tissues
Excretion: mostly urine, feces,
breast milk
Half-Life: 4-6 hrs
salbutamol
Pharmacokinetics
provides a comparison of asthma medications (relievers and controllers), their actions, side effects
MDI(CFC) – Metered dose inhaler, chlorofluorocarbon propelled
and pharmacokinetics.
The following table
Medications: Relievers & Controllers
73
73
Apo-Theo-LA SRT®
Novo-Theophyl SRT®
Quibron-T®
Theochron SRT®
®
Theolair
74 SRT
• Flovent® Diskus® PD 50µg, 100µg, 250µg and 500µg
• Flovent® MDI(CFC) 25µg, 50µg, 125µg and 250µg
fluticasone
• Pulmicort® Nebuamp® Wet Nebulization 0.125mg/ml,
0.25mg/ml and 0.5mg/ml
• Pulmicort® Turbuhaler® PD 100µg, 200µg and 400µg
budesonide
• Alti-beclomethasone MDI(CFC) 50µg
• QVAR® MDI(HFA) 50µg, 100µg
beclomethasone
Medications
Glucocorticosteroids (inhaled):
Glucocorticosteroids (inhaled):
Controllers
Uniphyl®
24-Hour: theophylline
•
•
•
•
•
theophylline
• Phyllocontin® SRT
aminophylline
Methylxanthine:
Medications
• Prevents and suppresses
activation and migration
of inflammatory cells
• Reduces airway swelling,
mucous production, and
microvascular leakage
• Increases responsiveness
of smooth muscle beta
receptors
Actions
• relaxes airway smooth
muscle
• may have some
anti-inflammatory effect
• clients may benefit
even when serum levels
are low
Actions
• A spacer should be used
with MDIs in order to
assist in further reduction
of possible side effects.
• Rinsing, gargling and
expectorating after
inhalation can minimize
these side effects.
• Inhaled route: (up to
equivalent of 1000 µg/day
beclomethasone):
• sore throat
• hoarse voice
• thrush
Side Effects
Absorption: 30% aerosol, 13.5% powder
Distribution: 10-25% in airways
(no spacer), 91% protein binding
Metabolism: liver
Excretion: less than 5% in urine,
97-100% in feces
Half-Life: 14 hrs
fluticasone
Absorption: 39%
(no spacer)
Metabolism: liver
Excretion: 60% urine, smaller amounts
in feces
Half-Life: 2-3 hrs
budesonide
Absorption: 20%
(no spacer)
Metabolism: minimal
Excretion: less than 10% in urine/feces
Half-Life: 15 hrs
beclomethasone
Pharmacokinetics
Therapeutic Range:
29-55µmol/L
Several drug interactions include:
• antibiotics
• birth control pills
Absorption: well absorbed (PO),
slowly absorbed (extended release)
Distribution: crosses
placenta, widely distributed
Metabolism: liver
Excretion: kidneys, breast milk
Half-Life: 3-13 hrs, increased in liver
disease, CHF and elderly; decreased
in smokers
theophylline
Pharmacokinetics
74
• Usually caused by a high
drug serum concentration
or the client’s inability to
tolerate the drug and
include:
• upset stomach with
heartburn
• nausea
• diarrhea
• loss of appetite
• headache
• nervousness
• insomnia
• tachycardia
• seizures
Side Effects
• Serevent® Diskus® PD 50µg
• Serevent® MDI(CFC) 25µg
salmeterol
• Foradil® PD 12µg
• Oxeze® Turbuhaler® PD 6µg and 12µg
formoterol
Long-Acting ß2 agonists:
methylprednisolone
SoluCortef®
SoluMedrol®
INTRAVENOUS
• Medrol® 4 mg and 16 mg tablets
methylprednisolone
• Prednisone 5 mg and 50 mg tablets
prednisone
ORAL
Glucocorticosteroids (oral/intravenous):
Medications
Onset of action: 1-3 minutes
Duration: 12 hours
formoterol
Onset of action:
10-20 minutes
Duration: 12 hours
salmeterol
• Promotes bronchodilation
through stimulation of
ß2-adrenergic receptors
thereby relaxing airway
smooth muscle
Actions
•
•
•
•
•
•
tremor
tachycardia
headache
nervousness
palpitations
insomnia
Oral route-long term
(more than 2 weeks):
• adrenal suppression
• immuno-suppression
• osteoporosis
• hyperglycemia
• hypertension
• weight gain
• cataracts
• glaucoma
• peptic ulcer
• ecchymosis
Oral or IV route-short term
(less than 2 weeks):
• weight gain
• increased appetite
• menstrual irregularities
• mood changes
• easy bruising
• muscle cramps
• mild reversible acne
Side Effects
Absorption: minimal systemic
Distribution: local
Metabolism: liver first pass
Excretion: unknown
Half-Life: 5.5 hrs
salmeterol
Absorption: rapid, lung deposition 21-37%
Distribution: plasma protein binding
approximately 50%
Metabolism: liver, extensive
Excretion: 10% unchanged in urine
Half-Life: approximately 8-10 hours
formoterol
Absorption: rapid
Distribution: widely distributed
Metabolism: liver
Excretion: urine
Half-Life: 18 to 36 hrs, depending
on the drug
IV steroids:
Absorption: well absorbed
Distribution: widely
distributed; crosses placenta
Metabolism: liver, extensively
Excretion: urine, breast milk
Half-Life: 3-4 hrs
prednisone
Pharmacokinetics
75
• Intal Ampules® Wet Nebulization 2ml:10mg/ml
• Intal® MDI(CFC) 1mg
sodium cromoglycate
• Tilade® MDI(CFC) 2mg
nedocromil sodium
Non-steroidal (anti-allergic) Anti-inflammatory:
76
• Accolate® 20mg tablets
zafirlukast
• Singulair® 4 mg, 5mg and 10mg tablets
montelukast
Anti-Leukotrienes:
Medications
• Inhibits inflammatory
cell mediators release
from mast cells
• Blocks the action of
leukotrienes that are
released by the membranes
of inflammatory cells in
the airways
• Note: Bioavailability is
reduced with zafirlukast
(Accplate) when given
with foods
Actions
headache
abdominal pain
stomach upset
taken in the pm to help
minimize side effects
headache
stomach upset
bad taste
cough
• throat irritation
• cough
sodium cromoglycate
•
•
•
•
nedocromil sodium
• headache
• indigestion
• stomach upset
zafilukast
•
•
•
•
montelukast
Side Effects
76
Absorption: poorly
Distribution: unknown
Metabolism: unknown
Excretion: unchanged mostly in feces,
bile and urine
Half-Life: 80 min
sodium cromoglycate
Absorption: 90% inhaled dose
swallowed; 2.5% of dose swallowed is
absorbed; inhaled drug that reaches
the lung is completely absorbed;
bioavailability 6-9%
Distribution: 28%-31% protein binding
Metabolism: liver (metabolite)
Excretion: unchanged in bile and urine
Half-Life: 1.5-2.3 hrs
nedocromil sodium
Absorption: rapid after oral
administration
Distribution: enters breast milk,
99% protein binding
Metabolism: liver
Excretion: feces, breast milk,
10% unchanged by kidneys
Half-Life: 10 hrs
zafirlukast
Absorption: rapidly
Distribution: protein binding 99%
Metabolism: liver
Excretion: bile
Half-Life: 2.7-5.5 hrs
montelukast
Pharmacokinetics
76
• Symbicort® Turbuhaler® PD 100/6µg, 200/6µg
budesonide and formoterol
• Advair® Diskus® PD 100/50µg, 250/50µg, 500/50µg
• Advair® MDI(HFA) 125/25µg, 250/25µg
Long-acting bronchodilators and inhaled steroids
fluticasone and salmeterol
• Combivent® MDI 20µg ipratropium/120µg salbutamol
• Combivent® Wet Nebulization 0.5mg ipratropium/
3mg salbutamol per 2.5ml vial
Two bronchodilators:
ipratropium bromide and salbutamol
Combination Drugs:
Medications
• the same as those
listed for each medication
separately
Actions
Side Effects
Pharmacokinetics
77
Appendix E: Device Technique
Medications: Inhalation Devices
Adapted with permission from The Lung Association: www.lung.ca/asthma/manage/devices.html
Asthma medications come in many forms. However, most often they are taken by the inhaled
route:
Metered Dose Inhaler (puffer)
Dry Powder Inhalers ( Diskhaler®, Turbuhaler®, Diskus®)
Nebulizer (used mostly with small children, therefore, not described in this Appendix)
78
Accurate technique for using these devices is extremely important. Individuals with asthma
should review the accurate use of these devices with a nurse, pharmacist, Certified Asthma
Educator or other appropriately trained health professional.
Inhalation Delivery System
The inhaled route is the most effective method to deliver the medication directly to the airways.
As a result of using the inhaled route, the total dose of medication required is greatly reduced
thereby reducing the chance for the medication to have a systemic effect.
A. Metered Dose Inhalers (MDI)
Metered dose inhalers (MDI), or puffers, deliver a precise dose of medication to the airways
when used appropriately. It is very important to have a good technique. A holding chamber
or spacer is recommended for use with a MDI, particularly for those not able to use a puffer
accurately. To tell if the puffer is empty: (1) calculate the number of doses used, or (2) invert
or shake it close to the ear several times and listen/feel for movement of liquid. One
advantage of using the MDI is that it is quite portable. A number of different metered dose
inhalers are available. Different pharmaceutical companies manufacture similar medications
that are in different inhalers.
Metered Dose Inhaler: Proper Use
1. Remove the cap from the mouthpiece and shake the inhaler.
2. Breathe out to the end of a normal breath.
3. a) Position the mouthpiece end of the inhaler about 2-3 finger widths from the
mouth, open mouth widely and tilt head back slightly, OR
b) Close lips around the mouthpiece and tilt head back slightly.
4. Start to breathe in slowly, and then depress the container once.
5. Continue breathing in slowly until the lungs are full.
6. After breathing in fully, HOLD breath for 10 seconds or as long as possible,
up to 10 seconds.
7. If a second puff is required, wait one minute and repeat the steps.
Care of a Metered Dose Inhaler
Keep the inhaler clean. Once a week, remove
the medication canister from the plastic casing
and wash the plastic casing in warm, soapy
water. When the casing is dry, replace the
medication canister in the casing and place the
cap on the mouthpiece. Ensure that the hole is
clear. Check the expiry date. Check to see how
much medication is in the inhaler as described
in the previous section.
Metered Dose Inhaler
79
Holding Chambers/Spacers
A number of different holding chambers are available from various companies. Different
companies make different devices. All these devices are effective. The difference between
them is the cost and durability.
80
Holding Chamber/Spacer
Holding chambers are devices that hold the medication for a few seconds after it has been
released from the inhaler. This is helpful for people who have trouble coordinating the spray
of the inhaler and breathing. It also allows the client the advantage of taking more than one
breath in for each puff when unable to hold their breath, particularly in an acute episode or
in the case of young children. There are masks available for adults or children with some of
the devices. The client must remember to wait a minute between each puff of the inhaler,
even when using a holding chamber. This ensures the client is receiving the prescribed
amount of medication. Holding chambers are indicated for all individuals who:
Use a Metered Dose Inhaler
Have trouble coordinating the hand-breath step
When a holding chamber and inhaler are used, the larger particles drop down into the holding
chamber. This limits the amount of particles in the mouth and throat, which in turn limits
the amount absorbed systemically and reduces the chance of side effects.
Using a holding chamber may prevent the hoarse voice or sore throat which can occur with
inhaled steroid use. Whether a holding chamber is used or not, individuals using inhaled
steroids should gargle after treatment.
Holding Chamber: Proper Use
1. Remove the cap on the inhaler (MDI) and holding chamber mouthpiece.
2. Shake the inhaler well immediately before each use. Insert the inhaler (MDI) into
the large opening of the inhaler adaptor on the chamber.
3. Put mouthpiece into mouth.
4. Depress inhaler (MDI) at beginning of slow deep inhalation. Hold breath as long
as possible, up to 10 seconds before breathing out. If this is difficult, an alternative
technique is to keep mouth tight on mouthpiece and breathe slowly 2-3 times after
depressing inhaler (MDI).
5. Administer one puff at a time.
6. Slow down inhalation if you hear a “whistling” sound.
7. Follow instructions supplied with the inhaler (MDI) on amount of time to wait before
repeating steps 3-6, as prescribed.
8. Remove the inhaler and replace the protective caps after use.
Care of a Holding Chamber
Whichever holding chamber is used, it must be cleaned at least once a week with warm soapy
water, rinsed with clean water, and air dried in a vertical position.
B. Dry Powder Inhalers (DPIs)
There are several dry powder inhalers available. Examples include the Diskhaler®,
Turbuhaler® and the Diskus®.
General points of dry powder inhalers include:
A quick forceful inspiration is required to deliver the medications to the lungs,
versus a slow breath for MDIs.
Some Dry Powder Inhalers contain a lactose carrier or filler.
81
Diskhaler®: Proper Use of a Diskhaler®
1. To load the Diskhaler®, remove the cover &
cartridge unit.
2. Place a disk on the wheel with the numbers
facing up & slide the unit back into the
Diskhaler®.
3. Gently push the cartridge in & out until the number
8 appears
in the window
4. The Diskhaler® is now ready for use.
82
5. Raise the lid up as far as it will go – this will pierce the blister.
Diskhaler®
6. Close the lid.
7. Breathe out.
8. Place the mouthpiece between the teeth and lips – make sure not to cover the air holes at
the sides of the mouthpiece.
9. Tilt head back slightly.
10. Breathe in deeply & forcefully.
11. Hold breath for 10 seconds or as long as possible.
12. Sometimes 2 or 3 forceful breaths in are needed to make sure all the medication is taken.
13. If a second blister is prescribed, advance the cartridge to the next number and repeat steps 5-11.
Care of a Diskhaler®
Remove the cartridge and wheel. Clean any remaining powder away using the brush
provided in the rear compartment before replacing the cartridge and wheel.
Turbuhaler®: Proper Use of a Turbuhaler®
1. Unscrew the cover and remove it.
2. Holding the device upright, turn the coloured wheel one way
(right) and back (left) the other way until it clicks. Once the click
is heard, the device is loaded.
3. Breathe out.
4. Place the mouthpiece between lips and tilt head back slightly.
5. Breathe in deeply and forcefully.
6. Hold breath for 10 seconds or as long as possible up to
10 seconds.
7. If a second dose is prescribed, repeat the steps.
Turbuhaler®
When a red mark first appears in the little window, only twenty doses remain. The
Turbuhaler® is empty and should be discarded when a red mark reaches the lower edge of the
window. Newer Turbuhaler® devices have a counter that appears in a little window to show
the number of doses left.
Care of a Turbuhaler®
Clean the mouthpiece two or three times a week. Using a dry cloth, wipe away any particles
which have collected on the mouthpiece. Never wash the mouthpiece.
Diskus®: Proper Use of a Diskus®
83
1. Open – Place thumb on thumb grip. Push thumb away from body as far as it will go.
2. Slide – Slide the lever until a click is heard. Breathe out away from the Diskus®.
3. Inhale – Seal lips around the mouthpiece. Breathe in steadily and
deeply through mouth. Hold breath for about 10 seconds, and then
breathe out slowly.
4. Close – Place thumb on thumb grip, and slide the thumb grip
towards body, as far as it will go.
Important: If more than one dose is prescribed, repeat steps 2-4. Rinse
your mouth after using Flovent® or Advair®.
Care of a Diskus®
The dose counter displays how many doses are left or when the inhaler
is empty. Keep the Diskus® closed when not in use, and only slide the
lever when ready to take a dose.
Diskus®
Appendix F:
What is an Asthma Action Plan?
What is an Asthma Action Plan?
An asthma action plan is an individualized written plan developed for the purpose of client
self-management of asthma (Gibson et al., 1999). The plan guides self-monitoring of asthma
based on symptoms, reliever use and perhaps peak flow measurements, and details the
management steps to take according to the level of asthma control. The action plan is
tailored to the individual’s preferences, treatment and usual pattern of exacerbations, and
84
may incorporate triggers. Action plans should be developed in partnership with clients.
Often asthma action plans use a traffic light analogy having a green, a yellow, and a red zone.
The green zone represents a time of acceptable and stable asthma control, and a “go ahead”
with current therapy. The yellow zone represents a time of “caution” in that there are signs
of worsening asthma and asthma control being lost. In response to this loss of control,
suggestions may be made to adjust medications and/or seek medical assistance. The red
zone represents a time of “danger” where asthma is identified as being out of control and
severe enough to warrant urgent medical attention.
When should a written Asthma Action Plan be provided?
The Canadian Asthma Consensus Report (1999) recommends that every individual with
asthma have a written action plan. An Ontario based survey of physicians observed that less
than 25% of physicians provided written action plans. Those with more severe asthma were
more likely than those with less severe asthma to receive an action plan (Cicutto et al., 1999).
An initial action plan should be provided when the diagnosis of asthma is established and/or
at the time of discharge from the emergency department or hospital. The level of detail in the
plan is dependent on the individual’s understanding and preferences. Key components for
teaching a patient how to use an action plan includes the signs and symptoms of worsening
asthma, how to adjust medications and when to seek medical attention, either an office visit
or urgent care. If the client has an action plan, careful questioning about the most recent
episode will elicit understanding of the plan, assess skills needed for executing the plan, and
identify the need for further education.
Key Points
The core of asthma management is the individualized asthma action plan.
An action plan outlines the criteria for determining control and informs
the client of the necessary steps to maintain or regain asthma control.
Overall, an action plan provides clients with a framework to understand
their asthma management.
What Should the Nurse Do?
85
Ask client if she/he has a written action plan.
NO
YES
•
•
Assess client’s knowledge and use of action plan
Assess inhaler technique
•
•
•
Discuss role and rationale of action plan
Provide sample plan to complete with physician
(Appendix G)
Assess inhaler technique
Appendix G: Sample Action Plans
Sample 1: Firestone Institute for Respiratory Care
Sample 2: Kaiser Permanente Center for Health Research
Sample 3: Kingston General Hospital Action Plan
86
Sample 4: University Health Network – The Asthma & Airway Centre, Toronto Western Hospital
Number of
Tablets
Times
per day
Other:
Airomir, Bricanyl, Salbutamol, Ventolin, Oxeze
chest tightness or cough:
Use as needed for wheeze, shortness of breath,
RESCUE INHALER
TABLETS
Other:
Serevent ( )
Oxeze ( )
Atrovent, Combivent ( )
Pulmicort ( )
Flovent ( )
QVAR ( )
Advair ( )
INHALERS
REGULAR TREATMENT
by
Times
per day
until you are back to your best,
then return to your usual treatment.
If your phlegm is yellow or green, add:
Other:
Pulmicort
Flovent
QVAR
Number of
inhalations
YOU MUST INCREASE TREATMENT TO:
5. Peak flow rate after “rescue inhaler” is below
4. Awakened at night by symptoms.
3. Increase in symptoms on waking.
2. Increase in cough and/or sputum.
1. Increasing need for “rescue inhaler”.
If ANY of the following occur:
WHAT TO DO IF YOU BECOME WORSE
Please take this card to every doctor’s appointment.
on
This card was brought up to date:
adjust this card.
Name:
Phone:
with an unfamiliar name, please have them
CLINIC NURSE
Times
per day
took prednisone.
Phone:
Number of
inhalations
you have asthma and the last date that you
Name:
If your pharmacist substitutes an inhaler
It is important to tell every physician that
RESPIROLOGIST
Day 7
Day 8
Day 9
Day 10
Day 2
Day 3
Day 4
Day 5
Please note: This action plan is designed
as a three-fold pamphlet.
back to your best in 5 days.
• If symptoms and/or peak flow rates are not
• If you continue to get worse OR
WHEN TO CONTACT YOUR DOCTOR
Day 6
Day 1
TAKE PREDNISONE TABLETS ( )
OR if your peak flow rate is below
INCREASING TREATMENT
IF YOU CONTINUE TO GET WORSE AFTER
Patient Name:
Hamilton, Ontario, L8N 4A6
St. Joseph’s Healthcare
RESPIRATORY HEALTH
FIRESTONE INSTITUTE FOR
ASTHMA TREATMENT CARD
Reproduced with permission of the Firestone Institute for Respiratory Care, St. Joseph’s Healthcare, Hamilton, Ontario
Sample 1: Firestone Institute for Respiratory Care
87
88
Able to do usual activities
Usual medications control asthma
Increased need for asthma medications
Increased symptoms longer than 24 hrs.
Very short of breath
Usual activities severely limited
Asthma medications haven’t reduced symptoms
Medical Alert
Usual activities somewhat limited
(including wakening at night due to asthma)
Increased asthma symptoms
Caution
No symptoms of an asthma episode
All Clear
LEVEL
DANGER
SIGNS
3
2
1
TAKE:
Dose
ADD:
Dose
Max # Times/day
Max # Times/day
Lips or fingernails are blue
OR CALL 911 NOW
GO TO THE HOSPITAL NOW
Difficulty walking and talking due to shortness of breath
AND CALL YOUR PROVIDER
Dose
Medicine
ADD:
Return to Level 1 when symptoms improve.
Medicine
Medicine
ACTION
NO IMPROVEMENT
AFTER
HRS
OR
EVEN MORE
SYMPTOMS
INCREASE IN
SYMPTOMS
DOING WELL
STATUS
Reproduced with permission of the Kaiser Permanente Center for Health Research, Portland, Oregon.
Sample 2: Kaiser Permanente Center for Health Research (Symptom Monitoring)
to
Able to do usual activities
Usual medications control asthma
to
Increased need for asthma medications
Increased symptoms longer than 24 hrs
Very short of breath
Usual activities severely limited
Asthma medications haven’t reduced symptoms
(50% of my best peak flow)
Less than
Peak Flow
Red Zone: Medical Alert
Usual activities somewhat limited
(including wakening at night due to asthma)
Increased asthma symptoms
(80 to 50% of my best peak flow)
Peak Flow
Yellow Zone: Caution
No symptoms of an asthma episode
(100 to 80% of my best peak flow)
Peak Flow
My best peak flow:
Green Zone: All Clear
LEVEL
DANGER
SIGNS
3
2
1
TAKE:
Dose
ADD:
Dose
Max # Times/day
Max # Times/day
ADD:
Lips or fingernails are blue
OR CALL 911 NOW
GO TO THE HOSPITAL NOW
Difficulty walking and talking due to shortness of breath
AND CALL YOUR PROVIDER
Dose
Medicine
Return to Level 1 when symptoms improve
Medicine
Medicine
ACTION
NO IMPROVEMENT
AFTER
HRS
OR
EVEN MORE
SYMPTOMS
INCREASE IN
SYMPTOMS
DOING WELL
STATUS
Reproduced with permission of the Kaiser Permanente Center for Health Research, Portland, Oregon.
Sample 2: Kaiser Permanente Center for Health Research (Peak Flow Monitoring)
89
Sample 3: Kingston General Hospital Asthma Action Plan
Reproduced with the permission of Kingston General Hospital, Kingston, Ontario.
“Asthma Action Plan”
For:
90
Predicted Peak Flow:
*Personal Best Peak Flow:
Developed By:
Date:
Approved By:
Date:
*Your action plan will be based on this number.
(This Action Plan is not considered active until approved and signed by a physician)
Maintenance Medications:
Reliever:
Controller:
Other:
Your Asthma Is In Control If:
You have no symptoms at rest, play, during the night or upon awakening.
You need your reliever medication less than four times per week (not including prior
to exercise or exposure to triggers).
Your breathing tests and/or peak flow readings are normal for you.
Caution:
If at any time you:
Are unsure
Feel panicky
Feel an overwhelming sense of doom
Contact your physician or go to emergency immediately. This action plan is a guideline only.
GREEN ZONE: In Control
❏ Take your______________ (controller)___puff(s)
You have no symptoms;
You are able to do normal activities and/or sports
______time(s) per day even if you are feeling well;
without being short of breath;
❏ Take your other maintenance medication as prescribed;
You are not waking up at night or early in the
❏ Take your _____________(reliever)___puffs prior
morning due to your asthma;
to exercise or exposure to triggers if necessary
You are using your normal amount of reliever
or for occasional symptoms (shortness of breath,
medication.
wheeze, cough).
OR
Peak Flow Above:
(≥80% personal best)
YELLOW ZONE: Worsening Asthma
You are short of breath on moderate activity, and/or
You need your
(reliever) more often than
usual, and/or
(controller)
puffs
times
per day for 10-14 days and then return
to the “Green Zone”;
You are waking at night or early in the morning with
asthma symptoms, and/or
❏ Take your
❏ Take your
(reliever)
puffs every
4 hours as necessary to relieve symptoms;
❏ If no improvement in your symptoms and/or peak
You are getting a cold.
OR
Peak Flow between:
flows in 2 days or your reliever only lasts for 2-3 hours
and
go to the “Red Zone”.
(60-80%personal best)
RED ZONE: Severe Asthma
Your reliever is lasting 2 hours or less and/or
You do not feel better or your PEFR is under
(70% personal best) 20 to 60 minutes after taking
You are short of breath, wheezing and/or have trouble
breathing at rest or with normal activities.
puffs every 20
mg now and daily for the
days;
❏ Call your doctor and see him/her within 24 hours
or right away if getting worse.
❏ Dr.
OR
Peak Flow between:
(reliever)
minutes up to a total of 3 times and then every 4 hours;
❏ Take prednisone
next
your reliever and/or
❏ Take your
and
Phone number:
(50-60% personal best)
EXTRA RED ZONE: Medical Emergency
Your reliever is lasting 2 hours or less and/or
❏ Go directly to Emergency or
You are unable to talk in sentences and/or
❏ Dial 911;
You have blueness around your lips and nails and/or
❏ Take your reliever medication as necessary on the
You are frightened by your asthma and/or
You are having a sudden severe attack.
OR
Peak Flow below:
(<50% personal best)
way to the hospital.
91
Sample 4: Toronto Western Hospital of the University
Health Network
Reproduced with the permission of the Asthma and Airway Centre
University Health Network – Toronto Western Hospital, Toronto, Ontario
92
Appendix H: Peak Flow Monitoring Tips
1. Monitoring Peak Expiratory Flow (PEF) may be useful in some clients, particularly those
who are poor perceivers of airflow obstruction.
2. Caution should be exercised in interpreting PEF results, as they are extremely effort
dependent, and should be used in conjunction with other clinical findings.
3. The client’s PEF technique should be observed until the practitioner is satisfied that the
technique produces accurate readings. (See Appendix I)
4. Home PEF should be linked to the assessment of symptoms in the action plan.
5. Clients who are using a PEF meter should be instructed on how to establish their personal
best PEF and use it as the basis of their action plan.
6. PEF devices must be checked regularly for accuracy and reproducibility of results.
7. Baseline morning and evening monitoring should be carried out over a number of weeks
and continued regularly, with the frequency adjusted to the severity of the disease.
8. Clients should be alerted to the significance of increased diurnal variation (evening to
morning changes) in PEF, greater than 15-20%.
9. The accuracy of a client’s peak flow meter should be determined at least once a year or any
time there is a question about its accuracy. Values from spirometry or another portable
meter should be compared.
Samples of Peak Flow Meters
Mini Wright®
Peak Flow Meter
Vitalograph®
asmaPLAN+
Truzone®
Peak Flow Meter
93
Appendix I:
How to use a Peak Flow Meter (PFM)
Follow these five steps for using a Peak Flow Meter:
1. Move the indicator to the bottom of the numbered scale.
2. Stand up, or sit upright.
94
3. Take a deep breath in, and fill lungs completely.
4. Place the mouthpiece in mouth and close lips around it.
5. Blow out as hard and fast as possible in a single blow.
Write down the value. If coughing occurred, the value is inaccurate. Do not record.
Repeat the test.
Repeat steps 1 through 5 two more times.
Take the highest result of the three, and record.
Finding the Personal Best Peak Flow Number
The client’s personal best peak flow number is the highest peak flow number achieved over
a 2 to 3 week period when asthma is under good control.
Each client’s asthma is different, and the “best” peak flow value may be higher or lower than
another person’s of the same height, weight, and sex. The action plan needs to be based on
the client’s personal best peak flow value.
To identify the client’s personal best peak flow number, have the client take peak flow readings:
At least twice a day for 2 to 3 weeks.
Upon awakening and before bed.
Prior to and 15 minutes after taking a short-acting inhaled bronchodilator (reliever).
Appendix J:
Tips for Improving Adherence
Build a partnership with the client by establishing mutual goals for asthma care.
Assess individual barriers to adherence, including misperceptions regarding asthma
and its management.
Assess any cultural or ethnic beliefs or practices that may influence self-management
activities, i.e., “In your community, what does asthma mean?”
Display open communication by showing attentiveness (i.e., eye contact), providing
encouragement with non-verbal communication (i.e., smiling, nodding), using verbal
praise for effective management strategies (i.e., “That is great” or “You did the right
thing”), and using interactive conversation style (i.e., ask open-ended questions).
Language should be clear, unambiguous, and presented using non-technical language.
Make sure that you seek client feedback and elicit their understanding.
Tailor the level and amount of education to suit the client.
Provide client education using multiple teaching strategies (discussion, written materials,
video, interactive websites).
Ensure that clients with asthma have adequate information to facilitate appropriate
self-management.
Promote the use of a written individualized asthma action plan.
Simplify treatment and the action plan as much as possible.
Encourage the client to use activities of daily living (i.e., shaving, brushing teeth, meal
time) as reminders to take medication.
Review and reinforce good inhaler technique.
Education to improve medication adherence should address the following:
The severity of the client’s asthma.
The pros and cons to treatment options.
The consequences of not following the treatment plan.
Erroneous beliefs that asthma medications are not needed.
Issues related to asthma medications:
Side effects of medications.
Clarify misperceptions, particularly related to use of steroids.
95
Appendix K: Resources
Resources for Assisting with Client Asthma Education:
Practice settings may access resources for educational materials and tools to provide asthma
education through several sources:
The Asthma Society of Canada 1-800-787-3880
The Lung Association 1-800-972-2636
Asthma and Allergy Information Association
Local community asthma clinics – see Appendix L
96
Pharmaceutical Companies:
Contact your local pharmaceutical representative.
Teaching Tools: Inhaler placebos, spacers, peak flow meters, posters.
Recognized Healthcare Internet websites:
The Asthma Centre – University Health Network – www.uhn.ca/programs/asthma/
Asthma in Canada – www.asthmaincanada.com
Asthma Society of Canada – www.asthma.ca/adults
Canadian Asthma Consensus Guidelines Secretariat – www.asthmaguidelines.com
Canadian Network for Asthma Care – www.cnac.net
Family Physician Airways Group of Canada – www.asthmaactionplan.com
The Lung Association – www.lung.ca
National Institutes of Health (US Department of Health and Human Services) –
www.nih.gov
Opportunities for Continuing Professional Development in Asthma Care:
Canadian Network for Asthma Care (CNAC) Approved Asthma Educator Programs:
The Canadian Network for Asthma Care (CNAC) has approved several asthma educator
programs. Please refer to their website (www.cnac.net) for a full listing of approved programs.
The Michener Institute for Applied Health Sciences is the primary program in Ontario.
Subject to other criteria for certification, graduates of these approved programs will be
eligible to sit for the Certified Asthma Educator (C.A.E.) Examination.
Asthma Educator Program of The Michener Institute for Applied Health Sciences –
Toronto, Ontario
For registration information:
Division of Continuing Education
The Michener Institute for Applied Health Sciences
222 St. Patrick Street, Toronto, ON M5T 1V4
Tel: 416-596-3101 ext 3162
1-800-387-9066 ext 3308
Email: ce@michener.ca
www.michener.ca
The Canadian Network for Asthma Care lists several approved programs provided in other
provinces and internationally by distance on their website at www.cnac.net/english/
certprograms.html.
The Lung Association
The Lung Association’s (Ontario) professional section, the Ontario Respiratory Care Society,
has an asthma educator’s interest group. This group offers an annual seminar, several
evening sessions, a newsletter and other educational opportunities throughout the year. Please
refer to the Ontario Respiratory Care Society’s home page at www.on.lung.ca/orcs/mission.html
or contact them at orcs@on.lung.ca.
97
Appendix L: Asthma Clinics in Ontario
The Canadian Network for Asthma Care (CNAC) is an association of associations.
Its mission statement is “through its member organizations, CNAC is dedicated to the promotion
of asthma care and education in Canada with the ultimate goal of reducing illness and death
caused by this common disease”.
It coordinates several activities of its member organizations in the asthma education area.
The CNAC does not offer medical advice, nor does it refer members of the public to medical
practitioners. However, the CNAC maintains a self-reporting listing of organizations, agencies,
98
and hospitals providing asthma education programs to individuals affected with asthma for
all provinces in Canada. This listing is by province, including Ontario.
Current information regarding these programs, location, referral process and service focus is
posted on the CNAC website at www.cnac.net/english/clinics.html.
Appendix M: Description of the Toolkit
Best practice guidelines can only be
successfully implemented if there are:
adequate planning, resources, organizational and administrative support as well as appropriate
facilitation. In this light, RNAO, through a panel of nurses, researchers and administrators
has developed a Toolkit: Implementation of Clinical Practice Guidelines based on available
evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding
the implementation of any clinical practice guideline in a healthcare organization.
The “Toolkit” provides step-by-step directions to individuals and groups involved in planning,
coordinating, and facilitating guideline implementation. Specifically, the Toolkit addresses
the following key steps in implementing a guideline:
1. Identifying a well-developed, evidence-based clinical practice guideline.
2. Identification, assessment and engagement of stakeholders.
3. Assessment of environmental readiness for guideline implementation.
4. Identifying and planning evidence-based implementation strategies.
5. Planning and implementing an evaluation.
6. Identifying and securing required resources for implementation and evaluation.
Implementing practice guidelines that result in successful practice changes and positive clinical
impact is a complex undertaking. The Toolkit is one key resource for managing this process.
The Toolkit is available through the Registered Nurses Association of
Ontario. The document is available in a bound format for a nominal
fee, and is also available free of charge from the RNAO website. For
more information, an order form or to download the Toolkit, please
visit the RNAO website at www.rnao.org/bestpractices.
99
Appendix N:
Implementation Resources
The following “patient pathway” was developed by Trillium Health Care, the
acute care community-based hospital that pilot implemented this best practice
guideline. This pathway is included here as an example of how one practice setting
adapted the recommendations in this guideline to meet their local needs. This tool
allowed the nurses to
target their assessment
and teaching to meet the
100
patient’s needs, and to
reduce duplication in care.
Reproduced with permission of Trillium Health Centre, Mississauga, Ontario.
Notes:
101
Notes:
102
Notes:
103
103
Notes:
104
February 2007
Nursing Best
Practice Guideline
Shaping the future of Nursing
supplement
Revision Panel Members
Supplement Integration
Lisa Cicutto, RN, PhD, ACNP, CAE
Team Leader
Associate Professor
University of Toronto
Toronto, Ontario
This supplement to the nursing best
practice guideline Adult Asthma Care
Guidelines for Nurses: Promoting Control
of Asthma is the result of a three year
scheduled revision of the guideline.
Additional material has been provided in
an attempt to provide the reader with
current evidence to support practice.
Similar to the original guideline publication, this document needs to be reviewed
and applied, based on the specific
needs of the organization or practice
setting/environment, as well as the
needs and wishes of the client. This
supplement should be used in conjunction
with the guideline as a tool to assist in
decision making for individualized client
care, as well as ensuring that appropriate
structures and supports are in place to
provide the best possible care.
Pat Bailey, RN, BN, MHSc, PhD
Professor
Sudbury, Ontario
Ann Bartlett, RN, BScN, MSc(c), CRE, CAE,
NARTC (dip.)
Nurse Clinician
Firestone Institute for Respiratory Health
Hamilton, Ontario
Julie Duff-Cloutier, RN, BScN, MSc, CAE
Assistant Professor
Sudbury, Ontario
Khiroon Kay Khan, RN, CAE,
NARTC/Dipl. in Asthma & COPD
Nurse Clinician
Asthma & Airway Centre
University Health Network
Toronto, Ontario
Jennifer Olajos-Clow, RN, MSc, CAE, APN/ACNP
Advanced Practice Nurse, Acute Care Nurse
Practitioner
Kingston, Ontario
Tim Pauley, MSc, PhD
Research Coordinator
West Park Heathcare Centre
Toronto, Ontario
Ruth Pollock, RN, MScN
Professor
Laurentian University/St. Lawrence College
Cornwall, Ontario
Suzy Young, RN, MN, ACNP
Acute Care Nurse Practitioner, Respirology
St. Mary’s General Hospital
Kitchener, Ontario
Heather McConnell, RN, BScN, MA(Ed)
Program Manager
Nursing Best Practice Guidelines Program
Registered Nurses’ Association of Ontario
Toronto, Ontario
A review of the literature suggests that adult
asthma continues to be poorly controlled
and remains a primary goal for asthma
care. A Canadian study, The Reality of
Asthma Control (TRAC), revealed that 97%
of individuals thought their asthma was
well controlled; however, only 47% had
controlled disease (Fitzgerald et al., 2006). Action
plans remain an essential component of
asthma care but only 11% of individuals
have an action plan. Since the publication
of our original asthma guideline in 2004,
there have not been dramatic changes in
asthma care. A review of the most recent
literature and asthma practice guidelines
published in Canada, the United States, the
United Kingdom and from the World
Health Organization over the last 3-4 years
does not suggest dramatic changes to our
approach to asthma care, but rather suggests
some refinements and stronger evidence
for our approach.
Revision Process
The Registered Nurses’ Association of
Ontario (RNAO) has made a commitment
to ensure that this practice guideline is
based on the best available evidence. In
order to meet this commitment, a monitoring and revision process has been established for each guideline every 3 years. The
revision panel members (experts from a
variety of practice settings) are given a
mandate to review the guideline focusing
on the recommendations and the original
scope of the guideline.
Members of the panel critically appraised
four international guidelines, published
since 2002, using the Appraisal of Guidelines
for Research and Evaluation Instrument
(AGREE, 2001). The guidelines were:
National Institutes of Health (2003).
National Asthma Education and
Prevention Program: Expert Panel
Report: Guidelines for the Diagnosis and
Management of Asthma,Update on Selected
Topics 2002 (Rep. No. 02-5074).
British Thoracic Society & Scottish
Intercollegiate Guidelines Network
(2003). British Guideline on the
Management of Asthma: A National
Clinical Guideline. (2005 Update).
Global Initiative for Asthma (2002). Global
Strategy for Asthma Management and
Prevention (updated 2005). (NIH
Publication No 02-3659).
Global Initiative for Asthma (2006).
Global Strategy for Asthma Management
and Prevention. [Online]. Available:
www.ginasthma.org.
asthma severity. Labeling clients by
severity can be misleading. A client that
has “mild” asthma or “severe” asthma
can have potentially life threatening
asthma. The best way to prevent an
asthma death is to keep asthma under
good control regardless of severity.”
The definition of asthma control is
evolving both nationally and internationally. The revision of this guideline is
consistent with the current parameters
for asthma control endorsed by the
Canadian Asthma Consensus Report
(Boulet et al., 1999). However, the revision
panel acknowledges that the definition
used in this supplement will require
re-assessment once the most recent
update of the Canadian Asthma
Consensus Report is released, to ensure
there is consistent messaging related to
this important aspect of asthma management. The most recent edition of the GINA
guidelines (GINA, 2006) suggest that the cut
off for some of the criteria for assessing
asthma control may be changing.
Background Context
The following reference is to be added to
the discussion of “What Causes Asthma”
on pg. 26 of the guideline under the section related to “Irritants – Tobacco
smoke”: RNAO guideline Integrating
Smoking Cessation into Daily Nursing
Practice (2003).
The following content is to be added to
the discussion of “What is Asthma” on
page 25 of the guideline: “Regardless of
the client’s asthma severity, any loss of
asthma control can potentially be
life-threatening. It is important to
emphasize asthma control when a nurse
is conducting an assessment rather than
The wording of the subheading on
page 27 is to be changed to read, “c)
Other factors that can trigger or make
asthma more difficult to control”. This
is to emphasize the importance of
achieving asthma control, regardless of
asthma severity.
The AGREE review resulted in all four of
these guidelines being used to inform the
revision process of the RNAO guideline.
2
Review/Revision Process
Flow Chart
New Evidence
Literature Search
Yield 1,140 abstracts
40 studies met inclusion criteria
Quality appraisal of studies
Develop evidence summary table
Revisions based on new evidence
Supplement published
Dissemination
Summary of Evidence
The following content reflects the evidence reviewed that either supports the original
guideline recommendations, or provides evidence for revision. Through the review
process, no recommendations were deleted. However, a number of recommendations
were re-worded for clarity or to reflect new knowledge and three new recommendations
have been added.
+
NEW
unchanged
changed
additional
information
new recommendation
Practice Recommendations
Recommendation 1
All individuals identified as having asthma, or suspected of having asthma, will have their level of asthma control
assessed by the nurse.
+
Additional Literature Supports
Bousquet et al., 2005
Recommendation 1.1
Every client should be screened to identify those most likely to be affected by asthma. As part of the basic respiratory
assessment, nurses should ask every client two questions:
■ Have you ever been told by a physician or a health care provider that you have asthma?
■ Have you ever used a puffer/inhaler or asthma medication for breathing problems?
(Level IV)
Recommendation 1.2
For individuals identified as having asthma or suspected of having asthma, the level of asthma control should be
assessed by the nurse. Nurses should be knowledgeable about the acceptable parameters of asthma control which are:
■ use of inhaled short-acting ß 2 agonist <4 times/week (unless for exercise);
■ having daytime asthma symptoms <4 times/week;
■ experience night-time asthma symptoms <1 time/week;
■ normal physical activity levels;
■ no absence from work or school; and
■ infrequent and mild exacerbations.
(Level IV)
The table on page 31 of the guideline should be updated to include a reference to the updated Canadian Asthma
Consensus Report (Becker et al., 2003).
+
Becker et al., 2003
Recommendation 1.3
For individuals identified as potentially having uncontrolled asthma, the level of acuity needs to be assessed by the
nurse and an appropriate medical referral provided, i.e., urgent care or follow-up appointment.
(Level IV)
Recommendation 2.0
Asthma education, provided by the nurse, must be an essential component of care.
+
Mager et al., 2005
3
Recommendation 2.1
The client’s asthma knowledge and skills should be assessed and where gaps are identified, asthma education
should be provided.
(Level I)
+
Paasche-Orlow et al., 2005
Recommendation 2.2
■ basic facts about asthma;
■ roles/rationale for medications;
■ device technique(s);
■ self-monitoring;
■ action plans; and
■ smoking cessation (if applicable).
(Level IV)
When educating on the various aspects of asthma and asthma control, it is important for the nurse to determine
if the person smokes, and if so provide counseling and education regarding smoking cessation. Clients with
asthma that smoke should be informed that they are at a higher risk for having poorly controlled asthma and
that it is likely that they will require more medication to control asthma than if they did not smoke. Education
related to smoking cessation has been added to the recommendation to reflect this area of focus. Recent strong
evidence suggests that smoking impairs the therapeutic benefits of corticosteroids (Chaudhuri et al., 2003; Chalmers et al.,
2002; Tomlinson et al., 2005).
+
New subheading on page 33 to read, “Smoking cessation (if applicable)” to be added, with reference to the RNAO
guideline Integrating Smoking Cessation into Daily Nursing Practice.
Chalmers et al., 2002; Chaudhuri et al., 2003; Eisner et al., 2005; Marabini et al., 2002; McHugh et al., 2003; RNAO, 2003; Tomlinson et al., 2005
Recommendation 3.0
Every client with asthma should have an individualized written asthma action plan for guided self-management.
(Level I)
This new recommendation has been created from the original Recommendation 3.1 which has been divided into
two separate recommendations. The purpose of this change is to emphasize the importance of all clients with
asthma having a written asthma action plan.
NEW
+
BTS/SIGN, 2004; GINA, 2006
Recommendation 3.1
An action plan should be developed in partnership with the healthcare professional and be based on the evaluation
of symptoms with or without peak flow measurement.
(Level I)
The wording of this recommendation has been modified to emphasize the fact that the client and healthcare
professional should work in partnership to develop the action plan. The change in the wording is for clarification
only, and there has been no change in the intent of the recommendation.
GINA, 2006; National Institutes of Health, 2003; Osman et.al., 2002; Powell & Gibson, 2006; Smith et al., 2005
4
+
Recommendation 3.2
For every client with asthma, the nurse needs to assess his/her understanding of the asthma action plan. If a client
does not have an action plan, the nurse needs to provide a sample action plan, explain its purpose and use, and
coach the client to complete the plan with his/her asthma care provider.
(Level V)
Recommendation 3.3
Where deemed appropriate, the nurse should assess, assist and educate clients in measuring peak expiratory flow
rates. A standardized format should be used for teaching clients how to use peak flow measurements.
(Level IV)
Recommendation 4.0
Nurses will understand and discuss asthma medications with their clients.
The wording of this recommendation has been modified to emphasize the need for action related to client education and medication use. The change in the wording is for clarification only, and there has been no change in
the intent of the recommendation.
+
Recommendation 4.1
Nurses will understand and discuss the two main categories of asthma medications (controllers and relievers) with
their clients.
(Level IV)
The wording of this recommendation has been modified to emphasize the need for nursing intervention related
to client education and medication use. As a component of asthma knowledge related to medications, there is
an emphasis on the need for the nurse to have knowledge of both categories of asthma medications and proper
device technique in order to provide client education.
+
Finn et al., 2003
Recommendation 4.2
Clients with asthma will have their inhaler/device technique assessed by the nurse to ensure accurate use. Clients with
sub-optimal technique will be coached in proper inhaler/device use.
(Level I)
The wording of this recommendation has been modified to emphasize that clients will have their inhaler/device
technique assessed. The change in the wording is for clarification only, and there has been no change in the
intent of the recommendation.
Recommendation 5.0
The nurse will facilitate referrals for clients with asthma as appropriate.
The wording of this recommendation has been modified to emphasize that it is clients with asthma who should
be referred to an asthma educator and/or additional asthma resources in their community. The change in the
wording is for clarification only, and there has been no change in the intent of the recommendation.
5
+
+
Recommendation 5.1
Clients with poorly controlled asthma will be advised to see a physician.
(Level II)
The wording of this recommendation has been modified to emphasize that clients with poorly controlled
asthma will be advised to see a physician. The change in the wording is for clarification only, and there has been
no change in the intent of the recommendation.
+
Baren et al., 2001
Recommendation 5.2
Clients with asthma should be offered links to community resources.
(Level IV)
The wording of this recommendation has been modified to emphasize that it is clients with asthma who should be
offered links to community resources. The change in the wording is for clarification only, and there has been no
change in the intent of the recommendation.
+
See Appendix K – pg. 13 of this supplement for additions to the published listing of community resources related
to smoking cessation.
Recommendation 5.3
Clients with asthma should be referred to an asthma educator in their community, if appropriate and available.
(Level IV)
The wording of this recommendation has been modified to emphasize that it is clients with asthma who should
be referred to an asthma educator. The change in the wording is for clarification only, and there has been no
change in the intent of the recommendation.
+
Powell & Gibson, 2006
Education Recommendations
Recommendation 6.0
Nurses working with clients with asthma must have the appropriate knowledge and skills to:
■ Identify the level of asthma control;
■ Provide basic asthma education; and
■ Conduct appropriate referrals to physician and community resources.
(Level IV)
The wording of this recommendation has been modified to emphasize that it is when nurses are working with
clients with asthma that they must have the appropriate knowledge and skills. The change in the wording is for
clarification only, and there has been no change in the intent of the recommendation.
6
+
Organization and Policy Recommendations
Recommendation 7.0
NEW
Access to asthma education should be available within a community.
(Level V)
This consensus recommendation has been made by the panel in the context of the strong evidence that supports
asthma education to achieve and maintain asthma control, and the literature that indicates there is a lack of
community asthma education programs.
+
Boulet et al., 1999; Cowie, Cicutto & Boulet, 2001; Gibson et al., 2006
Recommendation 8.0
It is essential that asthma educators obtain and maintain the certified asthma educator (CAE) designation.
(Level V)
This consensus recommendation has been made by the panel in support of the Canadian Asthma Consensus
Report (Boulet et al., 1999), which suggests that educational programs for asthma educators that result in national
certification may standardize the information provided to clients with asthma, and improve the quality of
client education. The Canadian Network for Asthma Care (2006) has established a national certification for
asthma educators in Canada, which addresses two key aspects of asthma educator education: up-to-date
knowledge about asthma; and a better understanding on the part of educators about educational theory and
process (Cicutto et al., 2005). National learning objectives (core curriculum) have been developed to provide a
common set of technical and teaching competencies for Canadian asthma educators. Proficiency in these
competencies is required for national certification (Canadian Network for Asthma Care, 2006).
NEW
+
Boulet et al., 1999; Cicutto et al., 2005; Canadian Network for Asthma Care, 2006
Recommendation 9.0
Organizations should have available placebos and spacer devices for teaching,sample templates of action plans,educational
materials, and resources for client and nurse education and where indicated, peak flow monitoring equipment.
(Level IV)
Recommendation 10.0
Organizations must promote a collaborative practice model within an interdisciplinary team to enhance asthma care.
(Level IV)
Recommendation 11.0
Organizations need to ensure that a critical mass of health professionals are educated and supported to implement
the asthma best practice guidelines in order to ensure sustainability.
(Level V)
Recommendation 12.0
Agencies and funders need to allocate appropriate resources to ensure adequate staffing and a positive healthy work
environment in order to provide asthma care consistent with best practice.
(Level V)
Wording of the recommendation has been modified to emphasize that appropriate resources and work
environment are necessary to provide asthma care consistent with best practice. The change in the wording is
for clarification only, and there has been no change in the intent of the recommendation.
RNAO, 2007 (in press)
7
+
Recommendation 13.0
Healthcare organizations will use key indicators, outcome measurements, and observational strategies that allow
them to monitor:
■ The implementation of guidelines;
■ The impact of the guidelines on optimizing client care; and
■ Efficiencies, or cost effectiveness achieved.
(Level IV)
A commitment to monitoring the impact of implementing the Adult Asthma Care Guidelines for Nurses:
Promoting Control of Asthma best practice guideline is a key step to determine whether or not practice
guidelines improve client outcomes. One way to approach this monitoring activity is to describe each
recommendation to be implemented in measurable terms, so that the health care team can be involved
in the evaluation and quality monitoring process. Refer to pg. 61 of the guideline for some suggested
monitoring indicators.
NEW
+
Edwards et al., 2005; Hysong, Best & Pugh, 2006
Recommendation 14.0
Nursing best practice guidelines can be successfully implemented only when there are adequate planning, resources,
organizational and administrative support, and appropriate facilitation. Organizations may develop a plan for
implementation that includes:
■ An assessment of organizational readiness and barriers to education.
■ Involvement of all members (whether in a direct or indirect supportive function) who will contribute
to the implementation process.
■ Dedication of a qualified individual to provide the support needed for the education and
implementation process.
■ Ongoing opportunities for discussion and education to reinforce the importance of best practices.
■ Opportunities for reflection on personal and organizational experience in implementing guidelines.
In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the Toolkit:
Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus.
The Toolkit is recommended for guiding the implementation of Adult Asthma Care Guidelines for Nurses: Promoting
Control of Asthma.
(Level IV)
Dobbins, Davies, Danseco, Edwards & Virani, 2005
+
8
Implementation Strategies
The Registered Nurses’ Association of Ontario and the guideline panel have compiled a list of implementation strategies to
assist health care organizations or health care disciplines who are interested in implementing this guideline. A summary of these
strategies follows:
■ Have at least one dedicated person such as an advanced practice nurse or a clinical resource nurse who will provide support,
clinical expertise and leadership. The individual should have good interpersonal, facilitation and project management skills.
■ Conduct an organizational needs assessment related to the care of adults with asthma to identify current knowledge
and further educational requirements.
■ Create a vision to help direct the change effort and develop strategies for achieving and sustaining the vision.
■ Establish a steering committee comprised of key stakeholders and interdisciplinary members committed to leading the change
initiative. Identify short term and long-term goals.
■ Identify and support designated best practice champions on each unit to promote and support implementation.
Celebrate milestones and achievements, acknowledging work well done (Davies & Edwards, 2004).
■ Provide organizational support such as having the structures in place to facilitate best practices in asthma care. For example,
having an organizational philosophy that reflects the value of best practices through policies and procedures. Develop new
assessment and documentation tools (Davies & Edwards, 2004).
Research Gaps and Implications
A number of researchers have looked at health literacy in relation to self-management and chronic illnesses including the health
outcomes of individuals living with asthma (Dewalt et al., 2004). In this research some measure of reading level has generally been used
as a proxy for literacy. The limited research that has been done in relation to health literacy and asthma self-care demonstrates that
higher literacy skills are associated with better self-care management (Dewalt et al., 2004; Paasche-Orlow et al., 2005; Rudd et al., 2004; Sleath et al., 2006;
Williams et al., 1998). As indicated, it is clear that the use of action plans in the self-management of asthma is associated with improved
asthma control (Gibson et al., 2006) and significantly reduced sudden death (Abramson et al., 2001). Although care providers believe that there
is a relationship between literacy and asthma self-control (Forbis & Aligne, 2002), to date no research has been identified examining
the relationship between health literacy, the use of action plans and the maintenance of asthma control.
Appendices
The review/revision process did not identify a need for additional appendices; however updates to the following appendices
are noted.
Appendix B: Glossary of Terms
The glossary has been updated to remove the term:
Metered Dose Inhaler, Chlorofluorocarbon Propelled – MDI(CFC):
This device is no longer
available in Canada.
The glossary has been updated to add the term:
Bronchospasm:
A contraction of smooth muscle in the walls of the bronchi and bronchioles, causing narrowing of the
lumen (airway).
Appendix C: Assessing Asthma Control
In order to be consistent with content changes in Recommendation 2.2, Smoking Cessation is to be added to the list of content areas
to be included in an asthma education program (pg. 69 of guideline).
9
10
Actions
• Once inhaled, it is converted in the lungs to its
active metabolite, which is
a potent glucocorticoid
that binds to glucocorticoid receptors in the lung
resulting in local
pronounced anti-i
nflammatory activity.
• Binds to IgE preventing
binding of IgE to the high
affinity FceRI receptor,
thereby reducing the
amount of free IgE that is
available to trigger the
allergic-cascade.
• This medication prevents
free serum IgE from
attaching to mast cells and
prevents IgE mediated
inflammatory changes.
• Paradoxical bronchospasm
p. 76 – Non-Steroidal Anti-inflammatory – Sodium cromoglycate (Intal) MDI(CFC) is no longer available in Canada
p. 74 – Glucocorticoids (inhaled) – Fluticasone (Flovent) MDI(CFC) is no longer available in Canada
p.75 – Long Acting ß2 Agonists – Salmeterol (Serevent) MDI(CFC) is no longer available in Canada
Controllers:
The following medications have been removed from the table:
p. 74 – Glucocorticoids (inhaled) – Fluticasone (Flovent) is now available in HFA in 50, 125 and 250 µg doses.
Controllers:
Side Effects
Anaphylaxis
Malignancy
Immunogenicity
Injection site irritation
Viral infections
Upper respiratory tract
infections
• Sinusitis
• Headache
• Sore throat
•
•
•
•
•
•
The following medication, included in the original guideline, has been updated as follows:
• Alvesco® MDI HFA 100 and 200 µg
Ciclesonide
Anticholinergic:
• Xolair® Subcutaneous 150mg. – 375mg. S.C. Q2 – 4 weeks.
Omalizumab
Anti – Immunoglobulin E (IgE) Neutralizing Monoclonal Antibody (Anti – IgE):
Medications
The following two new medications have been added to the medication table (pg 74) under Controllers:
Appendix D: Asthma Medications
Absorption: The systemic bioavailability for the active
metabolite is >50% by using the ciclesonide MDI.
Distribution: High protein binding, approximately 1% is
available for systemic exposure.
Metabolism: Hydrolysed to its pharmacologically active
metabolite by esterase enzymes primarily in the lungs.
Excretion: Liver – bile
Half-Life: Approximately 6 hours.
Absorption: Average absolute bioavailability of 62%.
Distribution : Peak serum concentrations after an average
of 7 – 8 days.
Metabolism: Liver
Excretion: Involved with IgG clearance via liver –
bile and in breast milk.
Half–Life: 26 days.
Pharmacokinetics
11
Number of
inhalations
Times
per day
Number of
Tablets
Times
per day
Other:
Airomir, Bricanyl, Salbutamol, Ventolin, Oxeze
tightness or cough:
Use as needed for wheeze, shortness of breath, chest
RESCUE INHALER
TABLETS
Advair ( )
QVAR ( )
Flovent ( )
Pulmicort ( )
Atrovent, Combivent ( )
Oxeze ( )
Serevent ( )
Spiriva ( )
Symbicort ( )
Other:
INHALERS
REGULAR TREATMENT
by
Day 8
Day 9
Day 10
Day 2
Day 3
Day 4
Day 5
5. Peak flow rate after “rescue inhaler” is below
Times
per day
until you are back to your best,
then return to your usual treatment.
If your phlegm is yellow or green, add:
Other:
Pulmicort
Flovent
QVAR
Number of
inhalations
Please note: This action plan is designed
as a three-fold pamphlet.
back to your best in 5 days.
• If symptoms and/or peak flow rates are not
• If you continue to get worse OR
WHEN TO CONTACT YOUR DOCTOR
Day 6
Day 7
Day 1
4. Awakened at night by symptoms.
YOU MUST INCREASE TREATMENT TO:
TAKE PREDNISONE TABLETS ( )
OR if your peak flow rate is below
INCREASING TREATMENT
IF YOU CONTINUE TO GET WORSE AFTER
Patient Name:
Hamilton, Ontario
St. Joseph’s Healthcare
3. Increase in symptoms on waking.
2. Increase in cough and/or sputum.
1. Increasing need for “rescue inhaler”.
If ANY of the following occur:
WHAT TO DO IF YOU BECOME WORSE
Please take this card to every doctor’s appointment.
on
This card was brought up to date:
adjusted.
Phone:
with an unfamiliar name, please have this card
If your pharmacist substitutes an inhaler
Name:
RESPIRATORY HEALTH
took prednisone.
Phone:
CLINIC NURSE
FIRESTONE INSTITUTE FOR
you have asthma and the last date that you
Dr:
ASTHMA TREATMENT CARD
It is important to tell every doctor that
RESPIROLOGIST
Sample 1 from Firestone Institute for Respiratory Care St. Joseph’s Healthcare, Hamilton Ontario (pg 87 of the guideline) is replaced with the updated version St. Joseph’s Healthcare
Hamilton “Asthma Treatment Card” below. Reproduced with permission.
Appendix G: Sample Action Plans
Sample 2 from Kaiser Permanente Center for Health Research (pg 88 of guideline) is current, with no revisions noted.
Sample 3 from Kingston General Hospital (pg 90 of the guideline) has been updated to reflect that the “Action Plan is not considered “active” until approved and signed by a physician”. Please note that if you are using this action plan as an example to develop
an organization specific Asthma Action Plan, you should provide space for a physicians’ signature.
Sample 4 from Toronto Western Hospital at the University Health Network, Toronto, Ontario (pg 92 of the guideline) is replaced with
the updated version below.
Reproduced with permission
12
Appendix H: Peak Flow Monitoring Tips
The labels of peak flow meters incorrectly identified on pg 93 of the guideline are corrected below. The samples illustrated here are
the meters that are most commonly used.
Truzone®
Peak Flow Meter
Personal Best®
Peak Flow Meter
Mini Wright®
Peak Flow Meter
Appendix K: Resources
The Educational Resources were reviewed in Appendix K for current contact information. The following updates to contact information
for Appendix K are listed below:
■ The Asthma Society of Canada: toll free number has been changed to: 1-866-787-4050 Toll Free Website: www.asthma.ca/adults
■ The Lung Association (National Office): 1-888-566-LUNG (5864) Website: www.lung.ca
■ The Lung Association (Ontario Office): Number remains the same 1-800-972-2636
■ The Asthma and Airway Centre – University Health Network: www.uhn.ca/Clinics_&_Services/clinics/asthma_airway.asp
■ Family Physician Airways Group of Canada: Website: www.fpagc.com
The following resources have been added to this appendix to reflect the new focus on smoking cessation in asthma education
provided to clients:
Resources for smoking cessation:
National
Canadian Cancer Society: www.cancer.ca
Smoker’s Helpline: 1-877-513-5333
Smoker’s Helpline Online: www.smokershelpline.ca
Canadian Council on Tobacco Control: www.cctc.ca
Health Canada: www.gosmokefree.ca
Heart and Stroke Foundation of Canada: www.heartandstroke.ca
Physicians for a Smoke Free Canada: www.smoke-free.ca
Provincial (Ontario)
Program Training and Consultation Centre: www.ptcc-cfc.on.ca
13
References
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15
March 2004
This project is funded by the
Ontario Ministry of Health and Long-Term Care
ISBN 0-920166-37-7

Free - Registered Nurses` Association of Ontario

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